
Class lliiifld 



Book. 






K 



CopyrigiitN . 



COPYRIGHT DEPOSIT. 



A TEXT-BOOK OF 

GYNECOLOGY 



EDITED BY 

CHARLES A. L. REED, A. M.. M. D. 

President of the American Medical Association 11900-1901 ) ; Gynecologist 

and Clinical Lecturer on Surgical Diseases ofAWfomen at the Cincinnati 

Hospital ; Fellow of the American Association! of Obstetricians and 

Gynecologists ; Fellow of the British Gynecological Society ; 

Corresponding Member of the National Academy of 

Medicine of Peru, etc.* 



ILLUSTRATED BY R. /. HOPKINS 



NEW YORK 

D. APPLETON AND COMPANY 

1901 






A 



THE LIBRARY OF 

CONGRESS, 
Two Copies Received 

APR. 4 1901 

Copyright entry 

CLASS ^XXc. N». 

COPY 8. 



Copyright, 1901 
By D. APPLETON AND COMPANY 



r 



TO 

R. C. STOCKTOX REED, M. D., LL. D. 

FORMER PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN THE 
CINCINNATI COLLEGE OF MEDICINE AND SURGERY 

THE LABOR OF THE EDITOR 

IX THE PREPARATION OF THIS WORK 

IS DEDICATED AS AN EXPRESSION OF FILIAL AFFECTION 



PKEFACE 



In the preparation of this work there has been held in view the 
three following special objects, viz.: 

1. The formulation of a Text-Bool- which shall serve as a working 
manual far practitioners and students, and which shall embrace the best 
approved developments of gynecology, including those of later date 
than are. or can be, included in a work of similar magnitude by a single 
author. 

For this purpose assignment of topics was made to a considerable 
number of writers, but only to those who have acquired reputation in 
connection with the subjects upon which they were asked to write. 
This division of labour, giving to each writer a relatively small amount 
of work, insured a careful preparation of copy in the shortest possible 
time, and the issuance of a strictly up-to-date volume. 

2. The co-operation of the various departments of medical science 
in their synthetic relation to gynecology. 

For this purpose contributions were invited from several writers 
who are not gynecologists in the strict sense of the term. Thus the 
various topics upon pathology were given to pathologists, while those 
relating to bacteriology, dermatology, neurology, hygiene, etc.. were 
assigned with similar appropriateness. As a consequence a single chap- 
ter, in some instances, is based upon contributions from several writers, 
while the whole has been rendered consecutive, systematic, and homo- 
geneous by the Editor. The work is not, therefore, in any sense a mere 
aggregation of monographs. 

3. The specific recognition of the work of investigators and oper- 
ators in gynecology and correlated departments. 

For this purpose invitations to contribute to the work were limited 
to those who had already contributed something to science. As a con- 
sequence writers were asked to treat their respective topics not only in 
a general way. but freely to express their individual views relative to 
the same. 

V 



yi A TEXT-BOOK OF GYNECOLOGY 

The Editor has rendered into the third person all references by the 
different writers to their own work. In this way and by reference to 
the table of contents, the reader is enabled to determine the authorship 
of each particular paragraph. 

The Editor feels a special sense of obligation to the contributors to 
the volume, whose clear and lucid comprehension of his objects and 
design and whose scholarly contributions have done much to lessen 
his task. 

The work of illustration has been in the hands of Mr. E. J. Hop- 
kins, whose previous special studies in anatomy as applied to art, and 
whose almost intuitive comprehension of the task, combined with ex- 
cellent technical skill on his part, has enabled him to add materially to 
the value of the book. 

Dr. Kenneth W. Millican, Assistant Editor of the New York Medi- 
cal Journal, has kindly seen the pages through print, and it is to his 
vigilance, industry and scholarly supervision, that the Editor is in- 
debted for the elimination of errors, which would have, otherwise, 
escaped detection. 

To Miss Georgia A. H. Isaminger, secretary to the Editor, acknowl- 
edgments are due for efficient service in transcribing and arranging 
manuscript. 

To the Publishers, the highest praise must be given for cordial 
co-operation at every stage of the work. 



Chakles A. L. Reed, Editor. 



Cincinnati, Ohio. 



CONTKIBUTORS 



J. W. Ballantyne, M. D.. F. R. C. P. E, F. R. R. 

Lecturer on Midwifery and Gynecology, School of the Royal Colleges. Edin- 
burgh. Scotland. 

J. H. Carstens, M. P. 

Professor of Obstetrics and Clinical Gynecology in the Detroit College of 
Medicine. Detroit, Mich. 

Murdoch Cameron, A. M., M. D.. F. R. C. S. 

Eegius Professor of Midwifery in the University of Glasgow. Glasgow, 
Scotland. 

Henry C. Coe. M. P.. M. R. C. S. 

Professor of Gynecology in the University of Bellevue Medical College. 
New York, X. Y. 

John G. Clark. M. A.. M. P. 

Professor of Gynecology in the University of Pennsylvania. Philadel- 
phia, Pa. 

F. X. Percoi. A. M., M. P. 

Clinical Professor of Diseases of the Nervous System in Jefferson Medical 
College. Philadelphia, Pa. 

Walter B. Dorsett, M. D. 

Professor of Obstetrics and Clinical Gynecology in the Beaumont Medical 
College. St. Louis, Mo. 

L. H. Punning, M. P. 

Professor of the Diseases of Women in the Medical College of Indiana. 
Indianapolis, Ind. 

Frank P. Foster, M. P.. LL. P. 

Editor of the New York Medical Journal. Xew York. X. Y. 

Samuel G. Gant, M. P. 

Professor of Rectal Surgery in the Xew York Post-Graduate Medical School. 
New York, X. Y. 

Hobart Amory Hare, M. A., M. P. 

Professor of Therapeutics in Jefferson Medical College. Philadelphia. Pa. 
Malcolm L. Harris. A. M., M. P. 

Professor of Surgery in the Chicago Polyclinic. Chicago. 111. 
Maximilian Herzog, B. S., M. P. 

Professor of Pathology in the Chicago Polyclinic. Chicago. 111. 

R. J. Hopkins, B. S. 

Artist. Xew York, X. Y. 

Joseph Tabor Johnson, A. M.. M. P. 

Professor of Gynecology and Abdominal Surgery in the University of 
Georgetown. Washington, D. C. 

vii 



viii A TEXT-BOOK OF GYNECOLOGY 

Wyatt G. Johnston, M. D., F. R. C. S. 

Professor of Bacteriology and Pathology in McGill College and University. 
Montreal, Canada. 

Matthew D. Mann, A. M., M. D. 

Professor of Gynecology in the Medical Department of the University of 
Buffalo. Buffalo, N. Y. 

Thomas Charles Martin, B. S., M. D. 

Professor of Pathology and Rectal Diseases in the College of Physicians and 
Surgeons. Cleveland, Ohio. 

Lewis S. McMurtry, M. D., LL. D. 

Professor of Gynecology and Abdominal Surgery in the Hospital Medical 
College. Louisville, Ky. 

Dan Millikin, M. D., LL. D. 

Former Professor of Materia Medica and Therapeutics in the Miami Medical 
College of Cincinnati. Hamilton, Ohio. 

Henry P. Newman, M. A., M. D. 

Professor of Gynecology in the College of Physicians and Surgeons of Chi- 
cago. Chicago, 111. 

William Warren Potter, A. M., M. D. 

Secretary of the American Association of Obstetricians and Gynecologists, 
and Editor of the Buffalo Medical Journal. Buffalo, N. Y. 

A. Ravogli, M. D., LL. D. 

Professor of Dermatology in the University of Cincinnati. Cincinnati. Ohio. 

Charles A. L. Eeed, A. M., M. D. 

Gynecologist and Clinical Lecturer on Surgical Diseases of Women at the 
Cincinnati Hospital. Cincinnati, Ohio. 

Hunter Robb. A. M., M. D. 

Professor of Gynecology in the Medical Department of the Western Reserve 
University. Cleveland, Ohio. 

James F. W. Ross, M. D., L. R. C. P.. England. 

Lecturer on Clinical Gynecology in the University of Toronto. Toronto, 
Canada. 

A. W. Mayo Robson, F. R. C. S. 

Professor of Surgery in the Yorkshire College of the Victoria University. 
Leeds, England. 

J. L. Rothrock, A. M., M. D. 

instructor in Pathology in the University of Minnesota. St. Paul, Minn. 

W. Japp Sinclair, M. A., M. D.. F. R. C. S. 

Professor of Obstetrics and Gynecology in Owen's College, Victoria Uni- 
versity. Manchester, England. 

Horace J. Whitacre, B. S., M. D. 

Lecturer on Clinical Surgery and Demonstrator of Pathology in the Univer- 
sity of Cincinnati. Cincinnati, Ohio. 

E. Gustave Zinke, M. D. 

Professor of Obstetrics and Clinical Midwifery in the University of Cincin- 
nati. Cincinnati, Ohio. 



CONTENTS 



Gynecology defined . 

Historical resume 

Gynecology as a specialty 

Nomenclature of gynecology 

Radicalism and conservatism in gynecology 



CHAPTER I 






PROLEGOMENA 




PAGE 




. Reed 


1 
1 

2 




. Foster 


3 


ovnecologv . 


. Reed 


4 



CHAPTER II 



GENERAL ETIOLOGY OF DISEASES OF 



Prevalence 
Causes 

Civilization . 

Education 

Personal habits . 

Occupation . 

Diseases 

Copulation . 

Prevention of concept 

Criminal abortion 

Childbirth . 

The social evil 



WOMEN 

Reed 



CHAPTER III 



GENERAL PATHOLOGY OF THE FEMALE GENERATIVE ORGANS 



Local pathology conforms to general pathologic laws 
Peculiarities depending- upon differentiated functions 
Menstruation ........ 

Ovulation in its relation to pathologic states 
Gestation in its relation to pathologic states 
The poise of the uterus and its variations . 
Bacterial origin of inflammatory diseases of the femal 
Tuberculosis ........ 

Syphilis ......... 

Trophic changes . 

Xeoplasms 



. Herzog 



genitalia . 



12 

12 
12 
13 
13 
15 
15 
17 
17 
17 
18 



A TEXT-BOOK OF GYNECOLOGY 



CHAPTER IV 

GENERAL THERAPEUTICS OF GYNECOLOGY 



General medication 
Serum therapy 
Local medication 
Balneotherapy . 
Suggestion 
Electricity 
Massage 



Reed 



PAGE 

20 
21 
22 
22 
23 
23 
24 



CHAPTER V 

THE GYNECOLOGICAL ARMAMENTARIUM 

The gynecological armamentarium . . . . . . Root) 



27 



CHAPTER VI 

DIAGNOSIS 

Definition and scope . 

Indications and contraindications for vaginal examination 

The gynecologic examination . 

Physical examination 

The armamentarium 

The examination itself 

Inspection of the external genitals 

Digital examination 

Bimanual examination 

Rectal exploration .... 

Examination under anaesthesia 

Auscultation, percussion, and general palpation of the ab 

domen .... 
Regions of the abdomen . 
Instrumental examination 

{a) The speculum 

(&■) The sound . 

(c) The dilator . 

(d) The curette . 

(e) The aspirator 
Examination of the secretions — 

Urines, faeces, menstrual fluid . 
Examination of the blood 
Examination of the nervous system 



Reed 


29 


„ 


30 


Potter . 


30 




31 


, 




31 


, 




33 


, 




34 


3 




35 


5 




37 


, 




39 


' 




40 


55 


40 


Reed 


41 


„ 


42 


Potter . 


42 


j? 


45 




45 


?j 


46 


„ 


47 


Reed 


47 


55 


49 






49 



CHAPTER VII 



SEPSIS 



Sepsis defined .... 

The bacteria of sepsis 

Local sepsis ..... 

Symptoms, pathology, treatment 
General sepsis 

Symptoms, pathology, treatment 



Reed 



50 
50 
55 
56 

57 

58 



Xll 



A TEXT-BOOK OF GYNECOLOGY 



Ether in its relation to bodily temperature 

Choice of anaesthetics in children . 

Bromide of ethyl .... 

Ether and its administration 

Mixed vapours and their administration 

Chloroform and its administration 

Management of accident in anaesthesia 

Anaesthetic mixtures 

Central anaesthesia by cocaine 

General anaesthesia by alcohol 

General anaesthesia by hypnosis 

Local anaesthesia 



Hare 



Reed 



PAGE 

89 
91 
91 
92 
93 
94 
95 
98 
97 
97 
98 



CHAPTER XII 

ABDOMINAL SECTION 

Terminology Reed . . 99 

Preliminary treatment of the patient ....... . . 100 

The evils of hypercatharsis ........ . 101 

Examination of the urines . „ . . 102 

Instruments Robb . . 103 

Location of the incision ....... Reed . . 103 

Direction and varieties . „ . 105 

The incision itself „ . . 107 

Closure „ . 109 

Drainage ............. . 114 

CHAPTER XIII 

THE EXTERNAL ORGANS OF GENERATION IN WOMEN 

Definitions Reed . . 117 

Development . . . . . . . . . „ . .117 

Malformations of — 

(a) Vulva ' . . . Ballantyne . 118 

(6) Vagina ., .126 

The hymen Reed . . 131 

Malformations of the hymen Ballantyne . 131 



CHAPTER XIV 



INJURIES OF THE 


EXTERNAL GENITAL ORGANS 




Injuries from — 




(a) External violence Dorsett . 


135 


(6) Parturition . 












., 


130 


(c) Sexual intercourse 














,. 


136 


Pudendal hematocele 














Reed 


136 


Injuries of the vagina 














V 


139 


Rupture .... 














„ 


139 


Urinary fistulae 














Ross 


139 


Vesico-vaginal fistulae 














„ 


139 


Sims's operation . 














Reed 


144 



A TEXT-BOOK OF GYNECOLOGY 



CHAPTER IV 

GENERAL THERAPEUTICS OF GYNECOLOGY 



General medication 
Serum therapy 
Local medication 
Balneotherapy . 
Suggestion 
Electricity 
Massage 



Reed 



PAGE 

20 
21 
22 
22 
23 
23 
24 



CHAPTER V 

THE GYNECOLOGICAL ARMAMENTARIUM 

The gynecological armamentarium ...... Root) 



27 



CHAPTER VI 

DIAGNOSIS 

Definition and scope . ..... 

Indications and contraindications for vaginal examination 

The gynecologic examination . 

Physical examination 

The armamentarium 

The examination itself . 

Inspection of the external genitals 

Digital examination 

Bimanual examination 

Rectal exploration .... 

Examination under anaesthesia 

Auscultation, percussion, and general palpation of the ab 

domen .... 
Regions of the abdomen . 
Instrumental examination 

(a) The speculum 

(fr) The sound . 

(c) The dilator . 

(d) The curette . 

(e) The aspirator 
Examination of the secretions — 

Urines, fasces, menstrual fluid . 
Examination of the blood 
Examination of the nervous system 



Reed 
Potter 



Reed 
Potter 



Reed 



29 
30 
30 
31 
31 
33 
34 
35 
37 
39 
40 

40 
41 

42 
42 
45 
45 
46 
47 

47 
49 
49 



CHAPTER VII 

SEPSIS 

Sepsis defined .... 

The bacteria of sepsis 

Local sepsis ..... 

Symptoms, pathology, treatment 
General sepsis ..... 

Symptoms, pathology, treatment 



Reed 



50 

50 
55 

50 

57 
58 



CONTENTS 



XI 



CHAPTER VIII 



ANTISEPSIS 



Antiseptic provisions of Natui 

Sterilization 

Mechanical means 
Heat .... 
Germicidal agents 

The nurse 

The room 

The patient 

Instruments and dressings 

Sutures and ligatures 

Post-operative antisepsis 

The surgeon 

Hand sterilization . 

Gloves .... 



Reed 



PAGE 

60 
60 
61 
61 
63 
63 
64 
66 
66 
67 
68 
69 
69 
70 



Definition 
Pathology 
Causes 
Symptoms 

Diagnosis . 

Treatment 

Prophylactic 
Restorative 



CHAPTER IX 

SHOCK 



Reed 



72 
72 
72 
73 
74 
74 
74 



CHAPTER X 



HEMORRHAGE AND HEMOSTASIS 



Hemorrhage 

Symptoms . 

Diagnosis 
Treatment of hemoi 
Hemostasis 

Styptics 

Heat . 

Pressure 

Angiotripsy 

Electric hemostasis 

Ligatures 



base 



Reed 



Newman 
Reed 



78 
78 
79 
79 
79 
79 
80 
80 
81 
83 
86 



CHAPTER XI 

ANAESTHESIA AND ANAESTHETICS IN GYNECOLOGY 

Definition Hare 

Anaesthetic agents .......... 

Race and temperament in the selection of an anaesthetic . „ 
Indications and contraindications for the use of chloroform 
and ether 



87 
87 
88 



xu 



A TEXT-BOOK OF GYNECOLOGY 



Ether in its relation to bodily temperature 

Choice of anaesthetics in children 

Bromide of ethyl 

Ether and its administration 

Mixed vapours and their administration 

Chloroform and its administration 

Management of accident in anaesthesia 

Anaesthetic mixtures 

Central anaesthesia by cocaine 

General anaesthesia by alcohol 

General anaesthesia by hypnosis 

Local anaesthesia 



Hare 



Reed 



PAGE 

89 
91 
91 
92 
93 
94 
95 
98 
97 
97 



CHAPTER XII 



ABDOMINAL SECTION 






Terminology Reed 


99 


Preliminary treatment of the patient 






•? 


100 


The evils of hypercatharsis 






„ 


101 


Examination of the urines 








,, 


102 


Instruments .... 








. Rol)b 


103 


Location of the incision 








. Reed 


103 


Direction and varieties 








55 


105 


The incision itself . . . 








55 


107 


Closure 








55 


109 


Drainage ..... 








55 


114 



CHAPTER XIII 

THE EXTERNAL ORGANS OF GENERATION IN WOMEN 

Definitions Reed . .117 

Development ............ • 117 

Malformations of — 

(a) Vulva " Ballantyne . 118 

(b) Vagina „ .126 

The hymen Reed . . 131 

Malformations of the hymen Ballantyne ■ 131 

CHAPTER XIV 

INJURIES OF THE EXTERNAL GENITAL ORGANS 

Injuries from — 



(a) External violence 












. Dorsett . 


135 


(&) Parturition . 












„ 


13G 


(c) Sexual intercourse 












j. 


136 


Pudendal hematocele 












Reed 


136 


Injuries of the vagina 












v 


139 


Rupture .... 












5? 


139 


Urinary fistulas 












Ross 


139 


Vesico-vaginal fistulae 






. 






55 


139 


Sims's operation . 












Reed 


144 



I ^ 



CONTENTS 



xm 



Vesicovaginal fistula?— 

Ross's operation 

Reed's operation 

After-treatment , 
Utero-vaginal fistula? 

Treatment 
Recto-vaginal fistula? 

Causes . 

Operation (Mayo Robson's 



Ross 



Mayo Robson 



PAGE 

145 
146 
148 
151 
151 
152 
152 
153 



CHAPTER XV 

INJURIES OF THE EXTERNAL GENITAL ORGANS— ( Contill lied ) 

Rape TT. Johnson 

Objective evidences ........ •> 

Local condition ........ „ 

Injuries on other parts ....... „ 

Condition of clothing „■ 

Schedule for examination „ 

Indecent assault „ 

Prolapse -, 

Injuries of perineum, vagina ....... „ 

Uterus .........:. „ 



156 

15G 
157 
158 
158 
159 
160 
161 
162 
162 



CHAPTER XVI 

INFECTIONS OF THE EXTERNAL GENITAL ORGANS 



Bacteriology of the external genital organs 
Mixed infections 
Gonorrhoea .... 

Tuberculosis .... 
Erysipelas .... 

Erysipelas and puerperal infection 
Diphtheria .... 

Aphtha? ..... 
Aerogenous infection 
Bilharzia ..... 
Chancroid ..... 



Reed 



Whitacre 

Reed 



R a cor/1 i 



163 
165 

166 
171 
177 
178 
179 
179 
180 
180 
181 



CHAPTER XVII 



DISEASES OF THE SKIN OF THE FEMALE GENITALS 



Intertrigo . 

Erythema . 

(Edema 

Eczema 

Folliculitis 

Herpes progenitalis 

Pruritus vulva? 

Pathology 

Causes 



Ravogli . 


191 


., 


194 


?? 


195 


„ 


196 


,, 


198 


., 


200 


„ 


202 


Reed 


203 


Ravogli . 


204 



XIV 



A TEXT-BOOK OF GYNECOLOGY 



Pruritus vulvae — 

Treatment Ravogli 

Surgical treatment Reed 

Parasitic affections ......... Ravogli 

Atrophy (kraurosis) „ 

Vulval adhesions Reed 



CHAPTER XVIII 

HYPERTROPHIC AND HYPERPLASTIC DISEASES OF THE PUDENDAL ORGANS 

Herzog 



Hypertrophy of the clitoris 
Condylomata 

Treatment 
Elephantiasis 
Polypi 

Treatment 



Ravogli 
Herzog 



CHAPTER XIX 

NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 



Benign neoplasms of the pudendum 

Varices 

Fibromyomata 

Pure myomata 

Myxomata . 

Lipomata 

Enchondromata . 

Cysts 
Benign neoplasms of the vagina 

Cysts 

Fibromata .... 

Treatment of benign neoplasms 
Malignant neoplasms of the pudendum 

Carcinomata 

Sarcomata 

Melano-carcinomata 
Malignant neoplasms of the vagina 

Sarcomata 

Carcinomata 

Treatment 

Clitoridectomy 

Extirpation of the vagina 

Palliative treatment . 



Herzog 



Rothroek 

Reed 
Herzog 



Rothrock 



Reed 



CHAPTER XX 

DISPLACEMENT OF THE VAGINA 



The vagina 

Varieties of displacements 

Cystocele .... 

Reetocele .... 

Urethrocele 

Colporrhaphy 

f 



Reed 



CONTENTS 



XV 



CHAPTER XXI 

THE VULVOVAGINAL GLAND PAGE 

Anatomy Rothrock . 243 

Gonorrhoea! infections . „ 244 

Abscess ........... „ 245 

Cysts . 247 

Carcinoma .......... „ 249 

CHAPTER XXII 



THE PELVIC FLOOR AND ITS INJURIES 



The pelvic floor .... 

The " pelvic diaphragm " 

Injuries ...... 

Laceration of the perineum 
Restorations of the pelvic floor 
Immediate operation 
Instruments . ... 

Operations for incomplete lacerations 

Superficial 

Emmet's operation 

Reed's method of suturing 

Modifications .... 
Operations for complete laceration 

Tait's operation .... 

Modifications .... 
Repair of deep injuries of the pelvic floor 

Harris's operation . 



CHAPTER XXIII 

CLASSIFICATION 

Malformations of the uterus Ball ant yne 

Embryonic „ 

Foetal 

Postnatal „ 

Absence „ 

Uterus unicornis „ 

Foetal, infantile, pubescent „ 

Uterus septus ......... „ 

Uterus bicornis „ 

Duplex uterus - 

Minor malformations Reed 

Treatment . „ 

Stomatoplasty „ 



Ret 


>d 


250 


j> 


253 


55 


253 


Dorsett . 


253 


Reed 


258 


„ 


258 


Robb 


259 


Reed 


260 


55 


260 


5" 


260 




263 


, 




265 


. 




267 


, 




267 


, 




269 


, 




271 


, 




272 



274 
274 
274 
275 
276 
276 
277 
277 
278 
278 
279 
280 
281 



CHAPTER XXIV 

DISPLACEMENTS OF THE UTERUS 

Normal position of the uterus . . . . . . Reed . . 284 

Displacements in general „ . . 285 

Varieties, causes, pathology „ . . 285 

Treatment Mann . . 288 

B 



XVI 



A TEXT-BOOK OF GYNECOLOGY 



Retro-displacements 
Symptoms and diagnosis 
Treatment 

Massage 

Pessaries 

Surgical ..... 

Shortening the round ligament; Alexander's 
vaginal operation; fixation operations 

Anterior abdominal cuneohysterectomy . 
Anterior displacements ..... 

Prolapsus ....... 

Inversion ....... 



peration 



Reed 



Mann 



Reed 

55 

Herzoy 
Reed 



CHAPTER XXV 

PARTURIENT INJURIES AND FOREIGN BODIES OF THE UTERUS 



Parturient injuries . 

Rupture . 

Laceration of the cervix . 
Trachelorrhaphy 

Instruments 
Vesico-uterine fistulse 

Reed's operation 
Nonparturient injuries 
Wounds from external causes 
Foreign bodies 



Reed 



Rooo 
Ross 
Reed 



CHAPTER XXVI 

INFECTIONS OF THE UTERUS 

The uterus .... 

The endometrium 

The secretion of the uterine cavity 

The myometrium 

Bacteria of the uterus 

Infections ..... 

Endometritis and metritis 

Pathology 

Causes 

Symptoms 

Diagnosis 

Treatment 
Topical 
Curettage 

Instruments 



McMu 
Reed 



Sinclair 
Reed 



Rolib 



CHAPTER XXVII 

infections of the uterus — {Continued) 



Specific — 

Gonococcous infection 
Streptococcous infection 



Reed 



2Tt2 

376 



CONTEXTS 



xvn 



Specific — page 

Tuberculosis infection Whitacre . 384 

Syphilitic infection Reed . .391 

Echinococcous infection ......... . . 393 

CHAPTER XXVIII 

NEOPLASMS OF THE UTERUS 



Neoplasms of the uterus in general 












. Herzog . 


. 396 


Benign neoplasms 

Fibroin yomata .... 

Causes, pathology, history . 

Secondary degenerations 












... - 


. 390 

. 396 

396-397 

. 399 


Diagnosis .... 












McMurtry 


. 402 


Complicating pregnancy 
Treatment .... 












" 


. 403 
. 404 


Medicinal and electrical 












„ 


. 404 


Surgical .... 












,, 


. 404 


Indications . . . . . 












Ross 


. 405 


Myomectomy 
Supravaginal hysterectomy 














. 407 

. 410 


Panhysterectomy 












.. 


. 415 


Reed's operation 












Reed 


. 417 


Vaginal myomotomy 
Extirpation of polypi 












Dunning 


. 420 
. 424 



CHAPTER XXIX 

NEOPLASMS OF THE UTERUS — (CO)lti )l lied) 



Malignant neoplasms 
Syncytioma malignum 

Pathology 

Histology 

Causes 

Symptoms . 

Treatment 
Adenoma . 

Symptoms 

Diagnosis 

Treatment 
Sarcoma 

Pathology 

Histology 

Symptoms . 

Causes 

Treatment 
Carcinoma 

Pathology 

Histology 

Causes . 

Symptoms . 

Pregnancy as a complication 



Reed 


42(5 


Herzog . 


426 


,. 


427 




427 


Recti 


42 S 


?> 


428 


.. 


429 


Herzog . 


429 


Reed 


431 


„ 


431 


,. 


431 


Herzog . 


432 


„ 


432 


„ 


-133 


Reed 


435 


V 


436 




436 


Her.zog . 


437 


„ 


438 


„ 


439 


Reed 


440 


>3 


442 




443 



XV111 



A TEXT-BOOK OF GYNECOLOGY 



Carcinoma — 

Palliative treatment Carstens 

Radical treatment Reed 

Vaginal hysterectomy Newman 

Instruments ......... Robb 

Abdomino-vaginal panhysterectomy .... Carstens 

Extended operation Reed 

Byrne's operation of electro -hysterectomy . . . ,, 

Results of hysterectomy ........ 



PAGE 

444 
447 

447 
448 
453 
453 
456 
458 



CHAPTER XXX 

CESAREAN SECTION AND ITS MODIFICATIONS 

Definition . . . . . . . . . . Cameron 

Historical resume „ 

Preparations .......... „ 

Position of child and placenta . . . ". . . „ 

The operation „ 

Sanger's method ......... „ 

Porro's modifications 



460 
460 
465 
465 
466 
470 
471 



CHAPTER XXXI 

MALFORMATIONS AND DISPLACEMENTS OF THE FALLOPIAN TUBES 

Absence and defective development .... 

Supernumerary and accessory tubes .... 

Accessory ostia ......... 

Displacements . . . . . . . . 



intyne 


. 473 


„ 


. 474 


55 


. 474 


}J 


. 477 



CHAPTER XXXII 



NEOPLASMS OF THE FALLOPIAN TUBES 



Benign neoplasms 
Papillomata 
Cystomata . 
Lipomata 
Fibromyomata 

Malignant neoplasms 
Carcinomata 
Sarcomata 



Reed 



478 
478 
480 
480 
481 
481 
481 
482 



CHAPTER XXXIII 

INFECTIONS AND INFLAMMATION OF THE FALLOPIAN TUBES 



Infections in general ...... 

Bacteria of the Fallopian tubes in health . 
Bacteria of the Fallopian tubes in disease 
Relations of infections to inflammation of the tubes 
Catarrhal salpingitis 
Morbid histology of salpingitis 

Acute 

Chronic .... 

Hydrosalpinx .... 



Reed 
Sinclair 

Clark 



483 

484 
484 
487 
489 
489 
489 
491 
495 



CONTENTS 



xix 



Hematosalpinx Clark 

Pyosalpinx 

Symptoms and diagnosis of salpingitis Robb 



PAGE 

499 
499 
501 



CHAPTER XXXIV 

INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 

Infections by — 

Gonococcus Reed 

Streptococcus 



Bacillus tuberculosis 

Bacillus coli communis 

Pneumococcus 

Staphylococcus 

Saprophytes 

Septic vibrion 

Actinomyces 



WMtacre 
Reed 



512 
516 
519 
528 
529 
530 
530 
531 
531 



CHAPTER XXXV 

TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 

The natural course and termination of inflammatory dis- 
eases of the Fallopian tubes Clark . . 532 

Hygienic treatment Coe . . 535 

Medicinal treatment ,. . . 536 

Local treatment „ . 537 

Massage . . 538 

Electricity Reed . . 539 

Drainage ............. . . 540 

Vaginal incision ......... . . 541 

Inguinal or inguino-vaginal . 542 

Abdominal and abdominovaginal ...... . . 544 

Rectal puncture ,. . . 546 

Aspiration „ . . 546 

Conservative operations on the tubes Coe . . 54(3 

Radical treatment Reed . . 549 

Salpingectomy . 549 

Tait's operation ........... . . 551 

Modifications of Tait's operation ...... . . 553 

Abdominal panhysterectomy ....... . . 554 

Doyen's operation ........... . . 556 

Modifications, indications, and limitations ..... . . 557 



CHAPTER XXXVI 

MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES 

Malformations BaUantyne 

Absence ..... 
Rudimentary development 
Accessory ovaries .... 
Coexistence of ovaries and testicles 



560 
560 
560 
561 
562 



XX 



A TEXT-BOOK OF GYNECOLOGY 



Displacements of the ovary . .... . . . Reed 

Decensus and prolapsus „ 

Hernia 



PAGE 

563 
563 
564 



CHAPTER XXXVII 

INFECTIONS AND INFLAMMATIONS OF THE OVARIES 



Classification 

Hypersemia . . . 

Acute inflammation 

Chronic inflammation 

Bacteria of the ovaries 

Individual infections 

Streptococcous infection 
Gronococcous infection 
Pneumococcous infection 
Bacillus coli communis infections 
Tubercular infections . . . 



Whitacre 


567 


Reed 


567 


j? 


568 


Whitacre 


569 


Sinclair 


570 


j? 


571 


Reed 


571 


!) 


574 


„ 


574 


JJ 


575 


Whitacre 


575 



CHAPTER XXXVIII 



TREATMENT OF INFECTIONS OF THE OVARIES 



Preliminary consideration 
Natural terminations 
Palliative treatment 
Conservative treatment 
Radical treatment 

Oophorectomy 
Unilateral 

Effects : primary, secondary 



Reed 


579 


„ 


579 


>' 


581 


•? 


582 


,, 


584 


J. T. Johnson 


584 


Reed 


585 




586 



Atrophy 
Cirrhosis 
Hypertrophy 



CHAPTER XXXIX 

TROPHIC DISEASES OF THE OVARIES 



Coe 


. 592 


Whitacre 


. 593 


Coe 


. 594 



CHAPTER XL 

NEOPLASMS OF THE OVARIES 

Small benign cysts . 
Follicular cysts 
Cysts of the corpus luteum 
Tubo-ovarian cysts 
Neoplastic cysts 
Proliferation cysts 
Dermoid cysts . 
Solid tumours . 

Fibroids 

Calcified tumours 
Hematoma 



Rothrock 


. 597 


,, 


. 598 


?> 


. 599 


„ 


. 601 


„ 


. 602 


'j 


. 602 


5J 


. 611 


,, 


. 614 


,, 


. 614 


Reed 


. 615 


Coe 


. 618 



CONTENTS 



xxi 



PARE 

Malignant neoplasms Rothroek . 619 

Carcinoma .......... „ 619 

Sarcoma „ 622 

Endothelioma 624 



CHAPTER XLI 

NEOPLASMS OF THE OVARIES (ConthUIC(l) 



Complications . 
Symptomatology 
Diagnosis . 
Treatment . 
Ovariotomy 

History 

Indications . 

Technique 

After-treatment . 
Incomplete ovariotomy 
Ovariotomy during pregnancy 



Reed 




627 


?j 




632 
633 

637 


J. T. 


Johnson 


638 
638 
639 
639 
645 


Reed 




646 

647 



CHAPTER XLII 

ECTOPIC PREGNANCY 



Historical resume 

Definition . 

Etiology 

Classification 

Course and termination 

Histology . 

Symptomatology 

Diagnosis . 

Treatment 



McMurtry 


649 


Herzog . 


650 


>j 


650 




652 




654 


,, 


656 


McMurtry 


660 




662 




664 



CHAPTER XLIII 



NEOPLASMS OF THE BROAD LIGAMENT 



The broad ligament .... 

Varieties of neoplasms 

Cysts (parovarian) .... 

Origin 

History 

Causes 

Symptoms, complications, diagnosis 

Treatment ..... 
Hall-Hawkins operation . 
Hydrocele of the long ligament 
Fibroma and myoma 

Symptoms, diagnosis, treatment 

Dermoids 

Solid tumours of the round ligament 

Pelvic varicocele, aneurismal varix, phlebolithiasi 

Carcinoma, sarcoma ..... 



Reed 
Zinke 



Reed 
Zinke 
Reed 
Zinke 



669 
669 
670 
671 
671 
674 
674 
675 
676 
677 
677 
679 
681 
681 
682 



XX11 



A TEXT-BOOK OP GYNECOLOGY 



CHAPTER XLIV 

INFECTIONS OF THE BROAD LIGAMENT AND OF THE PELVIC PERITONEUM 



Infections of the broad ligament 


. Reed 


688 


Pyogenic ....... 


„ 


688 


Pelvic abscess — treatment .... 


„ 


689 


Syphilitic infection 


„ 


690 


Tuberculous infection 


. Whit acre 


691 


Tubercular peritonitis 


,, 


692 



CHAPTER XLV 

MENSTRUATION 

Normal menstruation Millikin . 699 

Time of appearance . . . . . . . . „ . .701 

Menstrual cycle . . . . . . . . . „ . • 704 

Quantity of discharge ., 704 

Character of discharge „ 705 

The inducing cause of menstruation ..... „ 706 

The role of the uterus „ 708 

The role of the Fallopian tubes . 709 

The role of the ovaries ........ „ . . 709 

The hygiene of menstruation . . . . . . . „ . .712 



Millikin 



CHAPTER XLVI 

THE DISORDERS OF MENSTRUATION 

Menorrhagia ...... 

General systemic causes 

Local causative diseases above the pelvis 

Pelvic causes 

Treatment 
Metrorrhagia 
Amenorrhcea 

Treatment 
Retention of the menses 
Dysmenorrhcea 
Intermenstrual pain 
Vicarious menstruation 
The menopause 



CHAPTER XLVII 

THE FEMALE URINARY APPARATUS 

Physical examination Harris 

Catheterization of the ureters » 

Pawlik-Kelly method „ 

Use of the uretercysto scope ....... „ 

Harris's urine segregator ....... „ 

Anomalies of the kidneys ....... „ 

Number „ 

Location ........... 

Form n 



714 
714 
714 
715 
716 
719 
720 
721 
723 
725 
734 
735 
738 



744 

746 
746 
747 
747 
749 
749 
750 
751 



CONTENTS 



xxm 



Movable kidney 

Etiology 

Pathologic anatomy 

Symptomatology 

Treatment . 
Anomalies of the ureters 
Strictures of the ureters 
Nephrocytosis . 
Nephrydrosis 

Pathologic changes 

Symptomatology 

Diagnosis 

Treatment 



Harris 



PAGE 

752 
753 
755 
757 
759 
760 
760 
762 
762 
763 
765 
765 
766 



CHAPTER XLVIII 

THE FEMALE URINARY APPARATUS- 



Renal infections 

Symptomatology and diagnosis 

Treatment 

Tuberculosis of the kidneys 

Pathologic changes 

Symptoms and diagnosis 

Treatment 
Renal calculi 

Pathology 

Symptoms and diagnosis 

Prognosis . , . 

Treatment . 
Tumours of the kidney . 

Pathology 

Symptoms and diagnosis 

Treatment 
Operations on the kidneys 

Nephropexy 

Nephrotomy 

Nephrectomy 



{Continued) 




. Harris . 


. 768 


„ 


770 


,, 


772 


„ 


772 


M 


773 


„ 


774 


„ 


775 


„ 


776 


,. 


778 


15 


778 


„ 


778 


,, 


780 


„ 


780 


., 


781 


,, 


785 


„ 


787 


„ 


787 


„ 


788 


„ 


788 


» 


789 



CHAPTER XLIX 

THE FEMALE URINARY APPARATUS — {Continued) 



Cystitis 

Etiology .... 

Bacteriology 

Pathologic changes 

Symptomatology and diagnosis 

Treatment .... 
Hyperemia .... 

Treatment .... 
Foreign bodies in the bladder . 

Treatment .... 



irris 




790 

790 
791 
792 
793 
794 
795 


5J 




796 
796 


„ 




798 



XXIV 



A TEXT-BOOK OF GYNECOLOGY 



Tumours of the bladder . 














. Harris 




Symptomatology and diagnosis 










)j 




Treatment 










55 




Urethral caruncle 














55 




Treatment 














55 




Carcinoma of the urethra 














55 




Treatment 














55 




Sarcoma of the urethra . 














55 




Diverticula of the urethra 














., 




Treatment 














}) 




Stricture of the urethra . 














,, 




Prolapse of the urethra . 














5' 




Treatment 














,, 




Foreign bodies in the urethra 














55 




Dilatation of the urethra 














,, 




The urachus 














Reed 




Vesico-umbilical fistula . 














5J 




Treatment 














„ 




Cysts of the urachus . . 














» 




CHAPTER L 


THE RECTUM 


Malformations . . . ■ Reed 


Examination 






Martin 




Displacements ... .... 






Reed 




General etiology of rectal diseases 






Gant 




Relation to intra-pelvic disease in women 






Martin 




CHAPTER LI 


INFECTIONS OF THE RECTUM 


Inflammation Gant 


Periproctitis . . . . ' 










55 




Gonorrhoea . . 










Reed 




Syphilis 










Gant 




Tuberculosis .... 










„ 




Surgical conditions resulting from i 


nfections 








„ 




Anal ulcer or fissure . 










Martin 




Ulceration of the rectum . 










55 




Fistulse .... 










„ 




Stricture 














Gant 





CHAPTER LII 

NEOPLASMS OF THE RECTUM 



Adenoma 


Gant 


Lipoma 




Fibroma 


55 


Papilloma ...... 





Angioma 





Terratoma ..... 


J) • 



CONTENTS 



xxv 



Retention cysts 
Myoma 
Enchondroma 
Malignant growths . 

Operations . 

Divulsion 

Proctotomy . 

Curettage 

Colostomy . 

Excision 
Hemorrhoids 

Injection 

Whitehead's operation 

Ligature 

Clamp-and-cautery 



Gant 



PAGE 

844 

844 
844 
844 
846 
840 
846 
846 
846 
847 
848 
851 
852 
852 
853 



CHAPTER LIU 

PELVIC DISEASES AND NERVOUS AFFECTIONS 

Neurasthenia Dercitm . . 856 

Symptoms „ 856 

Conclusion . „ 860 

Hysteria „ . . 860 

Symptoms „ 860 

Pathology . 862 

Conclusions .......... „ . . 864 

Operations for the neuroses „ 864 

Nervous symptoms of pelvic disorders „ 865 



A TEXT-BOOK OF GYNECOLOGY 



CHAPTER I 

PROLEGOMENA 

Gynecology — Historical resume — Gynecology as a specialty — Nomenclature of 
gynecology — Radicalism and conservatism of gynecology. 

Gynecology. — This word (derived from ywr/, a woman, and Aoyos, 
understanding) implies, etymologically, the study or understanding of 
woman; but in its applied, modern sense, it means a consideration of 
the names, causes, prevention, symptoms, diagnosis, pathology, and 
treatment, of diseases peculiar to women. 

Historical Resume. — The evidence revealed by numerous papyri 
establishes beyond doubt that the ancient Egyptian physicians under- 
stood somewhat of the diseases of women, and that there were practi- 
tioners who devoted themselves especially to their treatment. The 
Mosaic writings reveal keen intelligence of the menstrual and repro- 
ductive functions; and the Talmud records the operation which subse- 
quently became known as the Cesarean. The Greeks, deriving their 
knowledge from the Egyptians, improved upon their inheritance, and, 
with the writings of Hippocrates, marked the beginning of gynecology 
in the sense of a systematic treatise on the diseases of women. Inflam- 
mations, the disorders of menstruation, and uterine displacements, here 
occur for the first time in recorded science. The writers of the next 
live hundred years simply elaborated upon the teachings of the great 
master. The speculum vaginae and the speculum ani were described by 
Galen, Avhile vaginal examinations by the digital method were practised 
long before that epoch. In the third century b. c, Soranus wrote a book 
on the uterus and pudendum. Aetius, Paul of JEgina, and other 
writers, show active and intelligent attention to divers diseases of 
women, including sterility. The speculum, duck-bill and multivalvu- 
lar, was in use, as were the uterine sound and uterine dilators. These 
instruments, and a knowledge of their use, however, seem to have 
dropped into oblivion during the long night of the Middle Ages. It was 
not until 1761 that Astruc, of the medical faculty of Paris, reinvented 
the speculum which he describes in his writing, but which passed with- 
out attracting the general attention of the profession. In 1801 Eeca- 
2 1 



2 A TEXT-BOOK OF GYNECOLOGY 

mier introduced his really practicable instrument by that name, an 
event which marked the revival of the long-lost gynecologic art. From 
this date progress has been rapid. In 1809 Ephraim McDowell, of 
Kentucky, did the first ovariotomy, an event which marked the begin- 
ning of intrapelvic gynecologic surgery. 

Uterine depletion by leeches (Guilbert); the use of the uterine 
sound (Lair); topical intrauterine and intravaginal treatment (Melier); 
the curette (Becamier); uterine pathology (Simpson); inflammation of 
the uterus (Bennet); anaesthesia (Wells-Simpson); the rediscovery of 
the univalve speculum (Sims); operation for vesico-vaginal fistulas 
(Sims); oophorectomy (Battey); pathology and operative treatment of 
the Fallopian tubes (Tait); infection of the upper genitalia (Noeg- 
gerath); perineorrhaphy (Emmet); antisepsis (Lister); and hemostasis 
(Koeberle), are among the more striking events which have character- 
ized the evolution of modern surgical gynecology. During this period 
it has been a constant beneficiary of the general development in the 
medical sciences. Many other names are entitled to be recorded upon a 
scroll more complete than is consistent with the limitations of this 
work. The aggregate result of such developments as are herein indi- 
cated comprises what is known as modern gynecology. It is obvious at 
a glance that the great steps that have been taken in the development 
of this department of medical science have been almost exclusively sur- 
gical; and with them, more conspicuously than any other names, must 
stand associated those of Marion Sims, Lister, and Lawson Tait. It 
must be admitted that the tendency to exclude rational therapy, in 
its broader and more general as well as in its local and special sense, 
from consideration in connection with the treatment of diseases pecul- 
iar to women, is an evil. The fact should be held in constant view, 
that gynecology is an integral and thoroughly correlated department 
of medical science. The gynecologist should, therefore, be grounded, 
not alone theoretically, but by years of actual practice, in all that per- 
tains to the most advanced state of the healing art, considered in its 
broadest sense. He should, moreover, keep himself in constant touch 
with medical science in the various phases of its evolution. 

Gynecology as a Specialty. — It is a fundamental law that progress 
is due to the gradual evolution of heterogeneity. This process is exem- 
plified, not alone in the various phases of organic life, but in complex 
social organisms. The medical profession, considered as a constituent 
element of the social fabric, is subservient to the same law. Special 
aptitudes and special knowledge lead to correspondingly special occu- 
pations. This comes as a result, not alone of the tastes and predilec- 
tions of the individual, but of the discrimination of those who become 
Iris patrons. It follows, therefore, that those who would assume to 
be specialists in any department of medical practice, but who are un- 
qualified for the responsibilities which they invoke, sooner or later 
must fail. Specialism in medicine has an ethical basis which can 
not be ignored. These facts render the segregation of medical science 



PROLEGOMENA 3 

in its practical application inevitable. There is no practitioner but 
knows and does some things better than he knows and does others, and 
he is to that extent a specialist. If, however, he were to concentrate 
his attention exclusively upon those things which he knows best and 
to ignore those things of which he knows least, his intelligence would 
move only upon convergent lines. This is indeed the inherent mis- 
chievous tendency of specialism, and one which the gynecologist, as 
other specialists, should never cease to resist. The sphere of the gyne- 
cologist's labours has already resulted in a broadening of his activ- 
ities. His constant experience with intraperitoneal conditions has 
resulted in his expansion into an abdominal surgeon, a fact recog- 
nised, not alone by the general consensus of the profession, but, spe- 
cifically, by the creation in medical schools of professorships of " gyne- 
cology and abdominal surgery," or of " abdominal and pelvic surgery." 
Nomenclature of Gynecology. — One of the chief embarrassments 
in the evolution of a science is an indetermined and essentially de- 
fective terminology. Words are but symbols, and each word, to prop- 
erly fulfil its office, should be easily and definitely translatable in the 
mind into that for which it stands. In this way alone can language 
subserve, in the highest degree, its legitimate function as a medium for 
conveying ideas from one person to another. The language of medi- 
cine, says Dr. Frank P. Foster, is by no means free from the defective 
neologisms that are to be found in the contemporary literature of the 
other sciences. That they are more abundant in the writings of gyne- 
cologists than in other medical writings he is not prepared to admit. 
He considers that their formation is for the most part to be attributed 
to the rage for designating diseases, operations, and the like, by single 
words. Their defects generally consist (a) in joining a Latin word to 
a Greek word to make a compound; (b) in adding a Greek termina- 
tion to a Latin word; (c) in reversing the proper order of the terms 
of a compound; or (d) in retaining an aspirate which any classical 
Greek writer would have suppressed. The following are examples 
of these forms of error: (a) " rectocolporrhaphy," made up of one 
Latin and two Greek words; (b) " annexitis," borrowed from the annex- 
ite of the French; (c) " hydronephrosis," instead of " nephydrosis " ; (d) 
" anhydrous " for " anydrous." Most of these defectively formed 
words have, however, established themselves firmly in the favour of the 
multitude, and it would be foolish to seek to root them out at this late 
day; nevertheless, by pointing out their deficiencies one may hope to 
moderate, in some degree, the further coining of objectionable terms. 
Far more to be regretted than these errors of coinage, is the perverted 
meaning often attached to well-known words, as when we say " differ- 
entiate " for " distinguish," or speak of " single " and " double castra- 
tion "; but even such perversions, however much they may offend the 
fastidious, throw no real obstacle in the student's way. The same can 
not be said, however, of the fancy that some authors have shown for 
dividing retroversion of the uterus, for example, into arbitrary " de- 



4 A TEXT-BOOK OP GYNECOLOGY 

grees." The need of the day, long since emphasized by Jonathan 
Hutchinson, is for the legitimate employment of well-understood 
words, preferably those that are short, easily remembered, and so far 
as possible in the vernacular. 

Radicalism and Conservatism in Gynecology. — The essentially sur- 
gical character of modern development in gynecology has led to some 
abuses that are the necessary incidents of all surgical evolution. The 
operations of tenotomy in orthopaedics, of tonsilotomy, and of the divi- 
sion of the recti muscles for the cure of strabismus, were followed imme- 
diately after their introduction, respectively, by indiscriminate applica- 
tion that resulted in damage to many patients. Other examples could 
be cited. In gynecology each new advance has been characterized by 
similar experiences. The use of the sound, of pessaries, and of caustics, 
was in each instance attended with early abuses. Emmet's operation 
for the repair of the lacerated cervix was followed by its needless per- 
formance in many cases. Oophorectomy and the more comprehensive 
operations upon the uterine adnexa were followed, immediately after 
their introduction, by efforts to relieve by their means conditions to 
which, in the light of subsequent experience, they were not adapted. 
These abuses, if such they can be designated, are to be construed rather 
as evidences of conscientious efforts on the part of the profession to 
determine the remedial value of surgical expedients. Reactionary in- 
fluences can be relied upon to correct these tendencies. The actuating 
motive in gynecology, as in other departments of medical and surgical 
practice, is to preserve in a safe or entire state, or to protect from unne- 
cessary loss, waste, or injury, the various organs or structures that are 
the seat of disease. Any departure from this criterion must be attended 
with danger. From this point of view, conservatism in gynecology is 
to be commended. It should be remembered, however, that even reac- 
tionary tendencies may go to dangerous extremes. This is sometimes 
exemplified in an effort to conserve an organ at the expense of the 
general health of the patient. On this point it is well to be governed 
by the rule tersely enunciated by S. C. Gordon (Philadelphia Medical 
Journal, August 19, 1899) that " conservative gynecology demands 
saving health rather than diseased and useless organs." 

All the splendid achievements of modern surgery, however, have 
been made in violation of the other equally legitimate definition of 
" conservatism " — namely: " Disposed to retain and maintain what is 
established, as institutions, customs, and the like; opposed to innova- 
tion and change; in an extreme and unfavourable sense opposed to 
progress." In view of the fact that the term conservatism of neces- 
sity carries with it the meaning expressed in the last as well as in the 
first definition, its introduction into the literature of gynecology is to 
be considered unfortunate. The life-saving impulse of the medical 
profession, and the yet unrelieved necessities of afflicted humanity, 
join in a demand for every innovation that will increase the efficiency 
of the healing art. 



CHAPTER II 
GENERAL ETIOLOGY OF DISEASES OF WOMEN 

Prevalence — Causes: Civilization; education; personal habits; occupation; dis- 
eases; copulation; prevention of conception; criminal abortion; childbirth; 
the social evil. 

There is a prevailing impression that the diseases peculiar to 
women are increasing relatively to the population. There exist no data 
upon which such an affirmation can be based. The impression probably 
depends for its existence upon the fact that such diseases are now 
better understood and more generally treated than formerly. Evidence 
is not wanting to indicate that the Anglo-Saxon woman is not degen- 
erating. Bowditch has made some interesting observations on the 
physique of women, as follows: Of over 1,100, he found that the average 
height was 158.76 centimetres (5 feet 3^ inches). Sargent, in nearly 
1,900 observations, the ages of the women ranging from sixteen to 
twent\ r -six, found the average slightly higher. Galton, in 770 measure- 
ments of English women from twenty-three to fifty-one years of age, 
also found a higher average — a difference due in part, no doubt, to the 
younger age of a number of the American subjects. In 1,105 subjects 
in ordinary indoor clothing Bowditch found the average weight to be 
56.56 kilogrammes (125 pounds). These observations, compared with 
276 by Galton, show that the average weight is a little greater among 
Americans. It would seem that while the tallest English women sur- 
passed the tallest American women in height, the heaviest American 
women exceeded the heaviest English women in weight. Specific ob- 
servation of this systematic character, however, is not necessary to im- 
press the intelligent traveller with the generally satisfactory physique 
of the women of England and America. It is true that many defective 
specimens are found, and these come with relatively greater proportion 
under the observation of the physician. But no one can fail to be 
impressed with the fact that they comprise a distinct minority of the 
masses. The improvement in the physique of women has been very 
noticeable since the sentiment for athletics has supplanted that for the 
cloister, and since outdoor exercises have taken the place of those seden- 
tary habits which, but a few decades ago, were considered the proper 
affectations of refinement. With that other and vastly larger class of 
people, who are not at liberty to choose their occupations, there has 
been a distinct improvement in physical estate. Improved habitations, 



6 A TEXT-BOOK OF GYNECOLOGY 

better hygiene, more humane regulation of occupation, more rational 
methods of education, and, with all, a more general diffusion of pros- 
perity, are responsible for this improvement. It is a source of regret 
that this more or less optimistic view must be tempered by a frank 
recognition of yet existing evils which, to a certain extent, retard the 
progressive improvement of womankind, and are largely responsible for 
the diseases which, in the aggregate, comprise the subject of this 
volume. 

Civilization. — The assumption has been made, and in some quarters 
entertained, that civilization, in the aggregate, exercises a deteriorating 
influence upon woman; that it develops her mind and brain and nervous 
system at the expense of other elements of her physical organism. 
There is no doubt that between the women of aboriginal peoples and 
those who belong to the civilized races there are certain physical dif- 
ferences, some of which tend to the production of sexual diseases in 
the latter. The reproductive function can be taken as an index. Sav- 
age women, as a rule, have but little difficulty in childbed, because they 
have large pelves and bear children with small heads. Accidents in 
childbirth, however, do occur among these primitive peoples with gen- 
erally fatal results. Currier (Medical Netus, 1891), who has studied the 
physical and sexual condition of the North American Indians, says: 
" that pelvic disease has not been treated among Indians does not prove 
that it does not exist." The fact that Indian women are very generally 
the victims of venereal diseases establishes upon a firm basis the pre- 
sumption that they must suffer from the remoter physical consequences 
of those diseases. Menstrual habits among many of the Indian tribes 
may well serve as an example to civilized women. The Mosaic rule that 
women during this period shall be put apart for seven days is observed 
in practice by these lowly people, who never heard of the records of 
Leviticus. Napheys, confirmed by Holder (American Journal of Ob- 
stetrics, 1392), says that " it is an inviolable rule among all these tribes 
for the women, when having their monthly sickness, to drop all work, 
absent themselves from their lodges, and remain in perfect rest as long 
as the discharge continues. " Measurements made by Holder indicate 
that the average height of the Indian woman is 5 feet 3-| inches; 
chest, 32| inches; waist, 29f^- inches; hips, 34-ff inches. The measure- 
ments of the perfect form of the civilized woman are given as follows: 
Height, 5 feet 5 inches; bust measure, 32 inches; waist, 26J inches; hips, 
35 inches. It would not seem from this comparison that civilization 
is producing the disastrous results with which it is accredited. On the 
contrary, there are many evidences of an improvement in the physique 
of women of the civilized type, in which improvement the genital 
organs are no doubt participating. 

Education. — Education of the conventional type has been held re- 
sponsible for many of the ills peculiar to women. This criticism had 
much more point and force a few decades ago when, the convent, 
with its seclusion and sedentary habits, determined the character of 



GENERAL ETIOLOGY OF DISEASES OF WOMEN 7 

women's education. The present, however, may be designated as the ra- 
tional epoch in women's education — one in which they receive the max- 
imum of physical, mental, and moral benefit with the minimum of in- 
jury. The most hopeful feature of the present regime is the tendency on 
the part of educators to study and regard the capacities and require- 
ments of the individual pupil. Eecognition is given to the primary bio- 
logic law of the antagonism between growth and genesis; and the effort 
is made in all advanced institutions of learning to adjust the curricula 
to the needs of the growing girl at different periods of her life. The 
doctrines of Froebel and Pestalozzi have relieved educational methods 
of much of their subjectivity, with the result that more attention is 
given to the education of the muscular system and the special senses; the 
book has largely yielded to the laboratory, and the cloister to the open 
volume of Xature. Potter (New York Medical Journal, 1891), recognis- 
ing some of the yet remaining defects of the educational system, sug- 
gests that for girls between twelve and sixteen, study hours or school 
work be restricted to four hours daily; that during each catamenial pe- 
riod the recitation room should be avoided; that during this period girls 
should indulge in much mental and bodily repose; and that during the 
school period especially, which is also the period of most active growth, 
girls should be provided with an abundance of wholesome food and be 
instructed in the most careful dietetic habits, special stress being laid 
upon a full morning meal. The dress should be constructed with ref- 
erence to relieving the waist line of all weight and pressure. He lays 
great stress upon the rule that no girl should enter a boarding school 
where the building is more than two stories high, and that stair climb- 
ing, at this developmental period of life, should be reduced to the 
minimum. Sir J. Crichton Browne urges that there are sexual brain 
differences between men and women which militate against the latter 
in higher education. While he admits that there are no trustworthy 
data for the estimation of the normal brain weight of healthy natives of 
Great Britain, he bases his conclusions upon the study of the brain of 
insane subjects, with the result that he finds the average excess of male 
over female brain weight to be 4.5 ounces, or, if allowance is made for 
the difference in bodilv height, the excess of the male over the female 
brain weight is reduced to 1.05 ounces. Sir James Browne asserts that 
the posterior brain development is greater in woman, that the convolu- 
tions have a similar pattern, and that her left brain weighs relatively 
less than her right; but there is a marked difference in the distribution 
of the blood to the brain in the two sexes, and from these observations 
the conclusion is drawn that women are not fitted for the same educa- 
tional tasks as are men. The whole argument is misleading, first, from 
the fact that the observations were made upon the brains of insane peo- 
ple; next, that they were not sufficiently numerous to justify a general 
conclusion; and, finally, that the results of higher education among 
women show that they improve physically as well as mentally, rather 
than deteriorate, under its influence. The last statement is confirmed 



8 A TEXT-BOOK OF GYNECOLOGY 

by Dr. Mary Dixon Jones, who, as a former principal of a young ladies' 
seminary, and latterly a successful practitioner with an extensive clien- 
tele among women, asserts that menstrual disturbances are of rare occur- 
rence, and that symptoms referable to the pelvis are but seldom com- 
plained of among young women students. The after life of such stu- 
dents indicates as good an average state of health and as high a degree 
of fecundity as among any other class. It is not apparent why intellec- 
tual occupation during the period of pubescence should interfere with 
sexual growth any more among girls than among boys. 

Personal Habits. — That personal habits have much to do in the 
causation of pelvic diseases can not be denied. Habitual errors of diet 
resulting in constipation; general physical inactivity inducing slug- 
gishness of the splanchnic circulation; and habits of dress seriously 
constricting the waist and imposing weight upon the pelvic viscera, are 
all to be taken into account. The corset, however, as an article of 
dress is not to be unqualifiedly condemned; on the contrary, if loosely 
applied, it serves as a protection rather than otherwise to the underlying 
viscera. More serious criticism should be directed to the deficiencies 
of dress of the neck, shoulders, arms, and legs. The influence of cold 
upon these more or less extensive areas can not but have a tendency to 
produce internal engorgements. Habits of outdoor exercise, now more 
or less prevalent, evince a hopeful tendency in the hygiene of women. 
Equestrian exercise, the bicycle, and golf, are all calculated to improve 
the physique of those who temperately participate in them. While 
this is true, it should not be forgotten that excessive activity in these, 
as in other wholesome sports, may be provocative of damage. 

Occupation. — The modern extension of woman's activities has 
brought with it more or less of a penalty in the form of genital diseases 
induced by her occupations. It was not to be expected that women 
could adjust themselves without damage to labours which, through 
generations, had been arranged for men; nor could it have been ex- 
pected that the several vocations could be at once so remodelled as to 
suit them to women's physical capacities. Clerking in stores, with its 
long hours of uninterrupted standing, employment in offices that were 
not provided with proper lavatory facilities, work in factories with im- 
perfect ventilation, and the carrying of heavy burdens, are among the 
examples which illustrate the influence of occupation as a cause of pel- 
vic disease in women. The peasant women of continental Europe work 
side by side with the men in nearly all occupations, and they are espe- 
cially given to carrying heavy burdens upon the head, as is true of the 
American negro in the South. All these classes furnish examples of 
uterine displacements — especially procidentia and its attendant evils. 
The relative robustness of the European peasant women is largely a fic- 
tion. The modern household has many features that have etiological 
bearings upon this class of diseases. The thoughtless construction of 
houses, carrying with it the necessity of excessive stair climbing; the 
totally unnecessarily great weight of household utensils that must be 



GENERAL ETIOLOGY OF DISEASES OF WOMEN 9 

handled b} T women; and the performance of overhead tasks, many of 
them unnecessary, are causes to be taken into account. The sewing 
machine, while a great mercy to womankind in general, is, by its abuse, 
a fruitful source of mischief to those whom it was designed to benefit. 

Diseases. — Aside from gonorrhoea and syphilis, mentioned in an- 
other paragraph, other diseases are provocative of genital disorders in 
women. Miiller, of Munich (C entralblatt fur Gyndkologie, 1890), has 
reported several cases in which miscarriages were induced by la grippe. 
The influence of the same disease upon the genital organs is noted by 
the same author, who finds that in a large number of cases it provokes 
either metrorrhagia, menorrhagia, or aggravation of sexual diseases 
already existing. Erysipelas may result in bacterial invasion and con- 
sequent suppuration within the pelvis and in puerperal fever. Neuras- 
thenia, a distinctly constitutional state, may occasion symptoms which 
Goodell appropriately designated as nerve counterfeits of genital dis- 
eases. Engorgements of the liver, from whatever cause arising, may 
produce disturbance of the portal circulation to a degree that will 
induce passive congestion of the pelvic viscera. Constipation is a fre- 
quent cause of functional disturbance of the ovaries and uterus. 

Copulation. — The sexual relation fulfils the meaning implied in 
the creation of two sexes. It is distinctly a physiologic function, yet 
errors in its establishment and practice frequently cause injury and 
disease in women. Coition, done abruptly for the first time, particularly 
if attempted by a male organ disproportionately large, may produce lac- 
erations and dangerous hemorrhage. A penis of inordinate length may 
penetrate a woman so far as to exercise undue violence upon the uterus 
and adnexa, and thereby sooner or later induce disease of those organs. 
If practised too frequently, or in the absence of inclination on the 
part of the woman, or if repeatedly completed by the man before an 
orgasm is experienced by the woman, it sooner or later becomes a mere 
source of mechanical irritation to the latter. Prostitutes suffer greatly 
in consequence of the nonamatory character of their sexual relations, 
although in such cases the constant possibility of infection as a com- 
plicating causative factor must be held in mind. Coitus reservatus when 
indulged in by the female has a tendency to increase to an abnormal 
degree the turgescence of the organs. Van de Warker made a critical 
study of forty-two women of the once notorious Oneida community, 
which seemed to have been organized chiefly with reference to the 
practice of coitus reservatus, especially by the male, but under condi- 
tions of promiscuity. He found no greater prevalence of sexual disease 
there than elsewhere, nor was he able to find diseased conditions which 
he could attribute to the sexual habits of the community. Sexual 
anaesthesia, of frequent occurrence in women, is a cause of unhappiness 
and physical injury. Sexual perversions are to be considered in the 
light of both cause and consequence of genital disease. Masturbation 
is often caused by a pre-existing local irritation of the vagina or puden- 
dum, or by adhesions of the clitoris to the prepuce, and it as frequently 



10 A TEXT-BOOK OF GYNECOLOGY 

causes similar disturbances. It is highly probable that there is no form 
of sexual perversion that is not associated with more or less congestion 
of the genital organs which remains after the act, whatever it may be, is 
completed. 

Prevention of Conception. — Malthus formulated a doctrine which 
assumed to justify the limitation of families by the prevention of con- 
ception. Practices having this object in view have been known since 
Onan spilled his seed upon the ground. Many accessory practices, how- 
ever, have come into vogue in modern times, none of which are destitute 
of serious consequences. The use of the vaginal douche immediately 
after intercourse, the use of a sponge within the vagina for absorbing 
the semen, the " womb caps/' condoms, are all damaging expedients. 
If it is granted that their local physical effects are not deleterious, the 
fact still remains that their employment implies a psychic state inim- 
ical to the perfectly normal performance of the copulative act. Coitus 
reservatus is generally more damaging to the male than to the female. 

Criminal Abortion. — There has been no time within the known his- 
tory of the human race when women have not sought to avoid mater- 
nity. The induction of abortion as a means of limiting reproduction 
was known and practised by the Egyptians, the Greeks, and the 
Eomans. Although certain social theorists have enunciated the prin- 
ciple of justifiable foeticide, it remains an unproved assumption that 
the practice is more prevalent to-day than in previous periods. That 
it is prevalent to-day, however, there is no denying; nor can the dele- 
terious results of the practice upon the reproductive organs of women 
be ignored. Infections induced in this way, when not fatal, almost 
always destroy fecundity and render relief by surgical means im- 
perative. 

Childbirth. — Many of the injuries and diseases of women have their 
origin in childbirth. The relatively large cranial development of chil- 
dren borne by civilized women, rather than any other one circumstance, 
tends to increase the difficulties and dangers of parturition. Infec- 
tion occurring in childbed, resulting in puerperal fever, or in infection 
of the endometrium or the Fallopian tubes, is yet of too common 
occurrence, although it is encountered with less frequency since the 
bacterial character of puerperal infections has become better under- 
stood. The recent great improvement in the obstetric art has already 
resulted in the practical disappearance of vesico-vaginal fistula and in 
the diminished frequency of both cervical and perineal lacerations. 
These conditions, however, are yet encountered as the demonstrable 
results of parturition. 

The Social Evil. — The social evil has long been recognised as re- 
sponsible for many of the physical infirmities of women. This evil, 
which has existed from the remotest antiquity and which will continue 
to exist as long as the race survives, is a necessary incident of social 
organization. It is properly recognised by all sociologists as an in- 
evitable feature of social evolution. In dealing with it, therefore, it 



GENERAL ETIOLOGY OF DISEASES OF WOMEN H 

is important at the outset to recognise it as an abiding fact rather than 
as an evanescent theory. In what way, therefore, does it exercise a 
deleterious physical influence upon society at large? The answer is 
that it works its mischief by the dissemination of the two great vene- 
real diseases, syphilis and gonorrhoea. 

Syphilis causes disease of the genital organs of women chiefly from 
the fact that it is communicated, for the most part, in the act of inter- 
course, and that the primary sore manifests itself in the genitalia. This, 
as a rule, is not an especially serious matter, although it may lead to 
the graver constitutional complications characteristic of the disease. 
In its hereditary form it is liable to manifest itself in defective develop- 
ments and in temperamental deficiencies, both of which may be mani- 
fested in defective functional capacity of the genital organs. The 
manifestations of this disease in relation to the different organs will be 
considered in their appropriate places in this work. 

Gonorrhoea, more than any other one disease, is responsible for those 
complications in women which are destructive of her reproductive ca- 
pacity, which produce organic disintegrations, and which demand sur- 
gical interference for their relief or cure. Before Noeggerath demon- 
strated that the gonococcus (see Microccocus gonorrhoea? under Sepsis) 
was the essential infectious element in the vast majority of intrapelvic 
suppurations, tubal and otherwise (see Pyosalpinx), gonorrhoea was 
looked upon as a local and comparatively trivial affection, involving the 
vagina and external genitalia. Since that time, however, the medical 
profession has come to recognise it as the most dangerous disease of 
frequent occurrence with which woman is afflicted, cancer, of course, 
being excepted. This assertion finds ample confirmation in the etiology 
and pathology of inflammatory diseases of women as presented in sub- 
sequent chapters. 

The social evil being recognised as a fixed and inevitable fact, and 
the dissemination through it of venereal disease being so destructive 
to women, it is the manifest duty of society to subject prostitution to 
the most rigorous supervision. The medical profession owes it to itself, 
and to the humane objects to which it stands consecrated, to use its 
influence to secure the legal regulation of that evil which society has 
proved itself unable to suppress. 



CHAPTER III 

GENERAL PATHOLOGY OF THE FEMALE GENERATIVE 

ORGANS 

Local pathology conforms to general pathologic laws — Peculiarities depending 
upon differentiated functions — Menstruation — Ovulation and gestation in their 
relation to pathologic states — The poise of the uterus and its variation — Bac- 
terial origin of inflammatory diseases of the female genitalia — Tuberculosis — 
Syphilis — Trophic changes — Neoplasms. 

Local Pathology conforms to General Pathologic Laws. — The gen- 
eral pathology of the female organs of generation in many respects does 
not differ from the general morbid anatomy and physiology of other 
parts of the body. Simple and specific inflammations, local bacterial 
infections, benign and malignant tumours, hypertrophy and atrophy, 
degenerations and other secondary changes, complications, and sequelae, 
follow the same pathologic laws and types as are observed elsewhere in 
the organism. There may be minor differences, but these variations do 
not involve any fundamental change in principle. Of such slight devia- 
tions from the ordinary there may be mentioned unusual degrees of 
glandular hypertrophy, often developing after slight inflammatory irri- 
tation, such as we find, for instance, in the mucous membrane of the 
uterus. There are tumours, ordinarily very malignant in type, which 
in some parts of the female genitalia — the ovary, for example — may 
exist for a long time without involving neighbouring structures or 
giving rise to metastases. On the other hand, tumours histologically of 
a benign type may produce purely mechanical disturbances by their 
rapid growth, location, or otherwise, which may endanger or even take 
the life of the patient. There are, however, also quite a number of 
morbid phenomena and conditions to which the female only is subject, 
and which must be studied from a strictly specialistic standpoint, with- 
out, of course, losing sight of the great general principles of pathology. 

Peculiarities depending upon Differentiated Functions. — The fe- 
male genitalia in the human race perform such specific and well-differ- 
entiated physiologic functions that we should expect to find in them 
disturbances unknown elsewhere. Such is the case; for the functions 
of menstruation, ovulation, and pregnancy, are often disturbed in their 
exercise by underlying abnormal changes which call for particular 
attention. 

Menstruation in its Relation to Pathologic States. — Menstruation 
brings about a cycle of profound though transitory changes in the 
12 



GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 13 

uterus. Congestion to a degree which anywhere else in the body would 
be abnormal, and actual hemorrhage, would, of course, be pathologic 
in any other organ but the female genitalia. It was formerly gen- 
erally held that the uterus in menstruation shed its whole mucous 
membrane, this being regenerated from what little remained of the 
glandular epithelium. Herzog, who has carefully examined several 
menstruating uteri obtained by operation from living subjects and not 
post-mortem, agrees with Mandl, Westphalen, Gebhard, and others, 
who within the last few years have maintained that the uterus does 
not shed its mucous membrane in menstruation, but only loses some 
of the surface epithelium. It being conceded that this view is cor- 
rect, there are then still present during and shortly after menstrua- 
tion some small patches of mucous membrane denuded of surface epi- 
thelium. This condition certainly favours bacterial invasion whenever 
microbes are present, and a locus minoris resistentice is thus created 
periodically in the female which does not exist in the male. Morbid 
subjective symptoms, the disturbances of beginning menstruation, dys- 
menorrhea, menorrhagia, amenorrhcea, and vicarious menstruation, are 
phases of pathologic phenomena necessarily peculiar to the female, and 
that are considered in detail in the section on Menstruation. 

We thus find that the function of menstruation may and does carry 
with it to the female, dangers and pathologic conditions from which the 
male is exempt. 

Ovulation in its Relation to Pathologic States. — We likewise find 
the same to be true with reference to ovulation. In it the physiologic 
processes and the accompanying tissue changes are of a type which 
may be well called quasi-pathologic. Paradoxical as it may appear, it 
may be well said that nowhere in the body do we have a physiologic 
process with such typical pathologic features as are found in ovulation. 
When a Graafian follicle has become mature and has approached the 
surface of the ovary there occurs at the time of ovulation a break in 
the continuity of the ovarian tissue, a rupture, accompanied by a hemor- 
rhage, which may be more or less extensive. The gap so formed is in 
the normal course of events closed by the formation of cicatricial tissue, 
derived from connective-tissue elements. Herzog, who has studied the 
normal and pathologic anatomy of the corpus luteum, agrees with Clark 
(Archiv fur Anatomie und Physiologie, 1898) , who has recently reaffirmed 
the view that the lutein cells are not epithelial cells derived from the 
zona granulosa, but connective-tissue elements derived from the theca 
interna folliculi. The processes of rupture, hemorrhage, and cicatri- 
cial-tissue formation, are, with this single exception, entirely patho- 
logic. (We will here neglect uterine menstrual hemorrhage, which is of 
a different character altogether.) In the ovary we find them as normal 
features of a purely physiologic process. It is obvious how easily these 
quasi-pathologic processes may overstep their physiologic limits and 
lead to truly morbid conditions, such as, for instance, marked cicatri- 
cial contractions with general premature atrophy of the ovary. Dan- 



14 A TEXT-BOOK OF GYNECOLOGY 

gers of ovulation to the female organism are also to be looked for in 
another direction. The normal living cells of the organism all pos- 
sess more or less the power to resist bacterial invasion. In ovulation, 
however, we have, formed in the female organism right in the perito- 
neal cavity, a blood coagulum, a focus, not consisting of living cells, 
but of a dead culture medium, which at the body temperature is so 
notoriously favourable to the development of pathogenic micro-organ- 
isms. It has been said above that menstruation, in consequence of 
slight denudation of the uterine mucous membrane, creates here a 
locus minoris resistentice for bacterial invasion. This is true in a 
still higher degree with reference to the formation of the blood coagu- 
lum in an open cavity of the ovary. Herzog, in studying the histology 
and bacteriology of a number of cases of ovarian abscess, was struck 
by the observation that in the large majority of cases one is able to dem- 
onstrate that the abscess wall contains elements of the corpus luteum. 
In other words, these abscesses represent an infection of the corpus- 
luteum cavity with pus formation (empyema of the corpus-luteum cav- 
ity). The proliferative processes in the normal adult body, as a rule, do 
not lead to the formation of newly organized tissues. They only sub- 
stitute tissue elements which in the cycle of metabolic changes have 
become senile, undergo dissolution, or are shed, as the case may be, 
and have to be replaced by younger elements. 

In the ovary, during sexual activity, with the ripening of the Graa- 
fian follicle we have constantly a process of real new tissue formation 
which, as a rule, stops only during pregnancy, but which may even then 
persist (Herzog: Superfoetation in the Human Kace. Chicago Medical 
Recorder, vol. xv, 1898). It is not improbable that the normal new 
tissue formation as found in the ovary in connection with the maturing 
follicle, stands in a certain relation as a predisposing, or even sometimes 
causative, factor in the development of neoplasms so frequently found 
in this organ. This view is here given in spite of the well-known fact 
that most neoplasms of the ovary are very likely of stromatogenous and 
not of ovulogenous origin. Among the neoplasms of the ovary, to be 
considered more in detail later, there is one of a most unique patho- 
logic histogenesis — namely, the dermoid cyst or embryoma ovarii. Her- 
zog strongly indorses the view so ably advocated by Wilms that these 
neoplasms are always of ovulogenous origin, not merely derivatives of 
ectodermal inclusions, and that they represent an attempt at patho- 
genesis. 

Gestation in its Relation to Pathologic States. — The most impor- 
tant physiologic function of the female genital organs, gestation, leads 
to numerous pathologic conditions and complications. Most of these 
lie outside of the scope of this work, but a number of them properly 
fall within the domain of gynecology. Minor congenital anomalies of 
a type which in other parts of the organism throughout lifetime may 
be void of any practical moment, when found in connection with 
female genital organs may become of the greatest pathological impor- 



GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 15 

tance. Some reference has already been made to this point when 
speaking of menstruation in the presence of a congenital obstacle to 
the catamenial flow. Of still greater practical bearing are those con- 
genital anomalies which become responsible for ectopic pregnancy. 
The etiology of the most frequent form of gestation of this kind — 
namely, tubal pregnancy — is as yet a good deal contested and obscure-. 
Herzog is of the opinion that in a large percentage, if not even in a 
majority, of cases, congenital anomalies are indeed the cause of ectopic 
gestation. Several cases have been reported in which there is left no 
doubt as to an etiology of this kind. (Henrotin and Herzog: Anomalies 
du Canal de Miiller comme cause des grossesses ectopiques. Revue de 
gynecologie et de chirurgie abdominale, Paris, 1898. — Very Early Rup- 
ture in an Ectopic Gestation in a Tubal Diverticulum. New York 
Medical Journal, 1899.) 

Pregnancy also furnishes the substratum of a peculiar kind of neo- 
plasm found in the female, the syncytioma malignum. These tumours, 
developing during or shortly after pregnancy, are derived from foetal 
structures — namely, the chorion epithelium, comprising the layer of 
Langhans and the syncytium. In some way or other these foetal ecto- 
dermal structures acquire the properties of a malignant tumour, develop 
parasitic properties, invade the parental structure, primarily the sexual 
organs, and form distant metastases. In this manner embryonic tis- 
sues may become the starting point of a malignant tumour which ulti- 
mately destroys the life of the maternal organism. Here we have again 
an example of a pathologic event directly dependent upon a function 
of the female organs of generation, an occurrence which is of course 
impossible in the male. 

The Poise of the Uterus and its Variations. — Among the peculiar- 
ities of the female sexual organs must be mentioned the delicate man- 
ner in which the uterus is balanced and held in position by the gen- 
eral arrangement of the parts in the female pelvis, in connection with 
a complicated ligamentary apparatus. It is very obvious why such a 
complicated arrangement should be necessary, when we consider the 
changes of position and size which the fruit bearer has to go through 
during the sexual life of the female. The delicacy of balance neces- 
sary from physiologic reasons becomes a fruitful source of morbid 
states. A very important and voluminous chapter in the pathology of 
the female sexual organs is that on the malpositions of the uterus. Of 
course, these malpositions are usually not of a primary nature; they are, 
as a rule, subsequent to other morbid changes. But these morbid 
changes per se are often very insignificant, and a long train of patho- 
logic sjmiptoms and conditions is only brought about in consequence 
of the changed position of the womb, its sequelae, and complications. 
(See Uterine Displacements.) 

Bacterial Origin of Inflammatory Diseases of the Female Genitalia. 
— If we now, from the standpoint of nosology, consider the general 
pathology of the female organs of generation, inflammatory diseases 



16 A TEXT-BOOK OF GYNECOLOGY 

first command our attention. After bacteriology had solved quite a 
number of questions with reference to general and local infections and 
inflammatory conditions in various parts of the organism, it was hoped, 
and firmly believed, that this youngest branch of pathology would also 
speedily contribute much toward showing us the true etiology of the 
great variety of inflammatory diseases of the female genitalia. The ana- 
tomic arrangement of the latter makes it a priori very probable that 
bacterial invasion plays a predominating role as a causative factor in 
all classes of inflammatory diseases. Doderlein, commenting upon this 
point with reference to such affections of the uterus, says: " Above any 
site in the body, the uterus seems to be the place favouring bacterial 
invasion and colonization. The open connection between the uterus, 
the vagina, and the outside world; the many chances for transport of 
germs which are so obvious, particularly during sexual life; stagnating 
secretions protected against desiccation and kept at a brood-oven tem- 
perature — all these factors unite to a priori impress us how well adapted 
the interior of the genitalia is for bacterial invasion and diseases de- 
pendent upon them." (See Sepsis.) 

Yet it has been found that, in spite of all these apparently favour- 
able factors, the internal genital organs of the healthy woman are not 
easily reached by pathogenic bacteria, and are, as a rule, sterile. The 
vulva, according to the unanimous verdict of all investigators, is fre- 
quently the seat of pathogenic bacteria, particularly the ubiquitous 
ordinary pyogenic micro-organisms. The vagina, however, in healthy 
women contains pathogenic bacteria only in a small number of the 
cases examined under the proper precautionary measures to avoid 
contamination. It, on the other hand, in healthy women always har- 
bours a great many nonpathogenic bacteria. Yet, fully virulent patho- 
genic microbes, introduced experimentally as has been done by Bumm, 
Menge, Kronig, Doderlein, and others, are speedily killed in the 
healthy vagina. Clinical and other experience has abundantly shown 
that the vagina under certain conditions loses its protective power of 
" self -purification." Particularly is this the case in parturition and 
immediately after delivery. A large percentage of septic inflammatory 
diseases of the female genitalia may be traced back to infection in par- 
turition. Such septic infection may, of course, also be easily induced 
in the nonpuerperal state by unclean instruments passed into the 
uterus. 

We know that malpositions or tumours of the uterus are responsible 
for hyperplastic inflammatory reactions of the endometrium. Deep 
lacerations of the cervix so frequently occurring in parturition, even 
without a manifest septic infection, may lead later on to chronic in- 
flammatory changes of the uterine mucous membrane. In other cases 
of endometritis we miss every tangible anatomic cause, and for an 
attempt at explanation we must turn to such flimsy causative factors 
as nutritional and circulatory disturbances of unknown origin — tropho- 
neurotic or vasomotor disturbances. It is, however, easy to understand 



GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 17 

that in the tissues of the female organs of generation there may be 
established frequently, without the aid of bacteria, the initial stages of 
inflammatory processes arising directly out of a plus of the physiologic 
functions. Congestion and stasis, or, in other words, dilatation of ves- 
sels and diminution of the velocity of the current, which are among 
the first steps in the train of inflammatory changes, are normally found 
in ovulation, menstruation, and pregnancy. 

The inflammatory diseases of the tubes and ovaries are often of 
very obscure origin, just like those of the uterus. This is particularly 
true of the ovary. In it we meet profound pathologic changes of this 
type, which baffle every attempt to get at their true cause as effectually 
as they resist all therapeutic measures. In such inflammations of the 
ovary we find cases with grave vessel changes, a pathologic process 
which has recently been described under the designation of angeiodys- 
trophia ovarii (Bulius and Kretschmer). 

Tuberculosis of the female genital organs, which may be a primary 
or a secondary process, is by no means so rare as was formerly believed. 
Some parts of the female genitalia are invaded frequently by the 
tubercle bacillus. Among these must be mentioned preferably the 
tube. It has been found that many cases of salpingitis, formerly be- 
lieved to be simply septic in character, are really mixed infections in 
which the tubercle bacillus is present. Even the ovary, formerly held 
to be practically free from tuberculosis, is not at all immune but is oc- 
casionally infected. In the uterine mucous membrane we find tuber- 
culosis in the acute miliary, the interstitial, and the ulcerative variety. 
Tuberculosis of the muscular coat seems to be rare, yet Herzog has seen 
a case in which the whole muscularis was literally studded with tuber- 
cles. (See Tuberculosis of the Various Organs.) 

Syphilis of the Female Genitalia. — Syphilitic manifestations of a 
primary, secondary, or tertiary type, are frequently found in the puden- 
dal organs, but very little is known about syphilis of the internal geni- 
tal organs except the occasional localization of the primary sore on the 
portio or cervix. Herzog, who has studied the vascular changes of 
syphilis (A Contribution to the Histopathology of Syphilis: Chicago 
Medical Recorder, vol. xiv, 1899), is of the opinion that certain cases 
of chronic oophoritis, in which no other causation can be obtained, and 
which present certain vessel changes very characteristic though not 
pathognomonic of syphilis, may be due to either the acquired or the 
congenital form of this affection. 

Trophic Changes. — Eeference has frequently been made to hyper- 
trophies occurring in the female genitalia. Just as we find a peculiar 
liability to hypertrophy in these parts, so do we meet atrophic processes, 
some of which have so far baffled all endeavours to solve their etiology, 
as is, for instance, the case in the atrophic condition known as kraurosis 
vulva?. (See Cutaneous Diseases of the Vulva.) Of course all normal 
physiologic senile changes must be excluded from the consideration of 
morbid atrophies, the most interesting of which are those of the uterus. 
3 



18 A TEXT-BOOK OF GYNECOLOGY 

Normal, transitory lactative hyperinvolution may lead to permanent 
premature atrophy. This may also be brought about by a number of 
general infectious diseases, abnormal blood states (leucaemia), or 
metabolic affections (diabetes). Profound puerperal infection is the 
most common cause of partial or total atrophy of the uterus, and this 
may lead to grave local and general disturbances. (Bacon and Herzog: 
Fatal Perforation of a Uterus Partially Atrophied Post-partum. Amer- 
ican Journal of Obstetrics, 1899.) 

Neoplastic Changes. — The true intrinsic etiology of tumour forma- 
tion in the female genital organs is as obscure to us in these parts as 
it is elsewhere in the organism. We know, of course, that the female 
genitalia are in an unusually high degree liable to become the seat of 
neoplasms. No part of these organs is free from tumour formation, 
and all types are met with. Three classes of new growth stand out 
most prominently. The horrible frequency of carcinoma of the uterus 
is a fact only too well known, not only to the profession, but even to 
the laity. 

While diseases of the mamma have been left out of our considera- 
tion entirely, it perhaps deserves mention here that these accessor}- 
sexual organs of the female likewise belong to those organs which most 
frequently develop carcinoma. The second class of tumours which show 
a great predilection for the female genitalia is formed by the fibro- 
myomata. Attempts have been made to explain their frequent devel- 
opment in the uterine muscularis upon the ground that the structure, 
from its physiologic changes in pregnancy, has an intrinsic tendency 
toward the new formation of muscle tissue. But this seeming explana- 
tion disregards the fact that while we have in pregnancy an enor- 
mous increase in the bulk of the muscularis, it is one, as is now con- 
ceded, winch does not depend upon an increase in the number of the 
component muscle cells, but only upon an increase in their size. The 
third class of neoplasms occupying a very prominent place in the 
pathology of the female organs of generation, is the cysto-adenomata of 
the ovary. It has been previously mentioned what physiologic reasons 
may possibly stand in some causal nexus to the frequency of neoplastic 
formations in the ovary. In the cysto-adenomata of the ovary we have 
epithelial neoplasms which differ greatly in some respects from ade- 
nomata found elsewhere. The latter, as a rule, have a great tendency 
to become malignant and to change into true carcinomata. This 
tendency in the cysto-adenoma of the ovary is rare. (Henrotin and 
Herzog: Carcinoma Developing in Primarily Nonmalignant Cysto- 
adenoma of the Ovary. Chicago Medical Recorder, vol. xvii, 1899.) 
Here we have an extensive epithelial proliferation, which in other parts 
of the body is almost sure to lead to carcinoma, but which in the ovary 
does not seem to carry with it any great danger of developing malig- 
nancy. Not only are these cysto-adenomata very common, but they also 
often occur in women advanced in life, and they may exist for years 
and decades without ever changing their benign type. Pathologic pro- 



GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 10 

cesses almost unknown in other parts of the body, bnt fairly often seen 
in the female in connection with benign epithelial neoplasms, are the 
implantation metastases of papillomatous adenomata of the ovary. 
These metastases are, as a rule, entirely void of true malignant features, 
and they generally disappear after the removal of the main tumour. 

Another fact worth remembering in connection with the peculiar- 
ities of the pathology of the female genitalia, is the comparative fre- 
quency of neoplasms, particularly of a sarcomatous type, in the female 
infant and child. 

In closing the foregoing considerations, it should be said that they 
do not pretend to furnish a full and exhaustive general description of 
all the pathologic phases and problems encountered in connection 
with the female genital organs. What has been attempted, is to give 
to the student of this department of medicine an idea of the special 
points of view and the particular physiological considerations from 
which the pathology of the genital system of the woman must be ap- 
proached, which are considered in detail in various chapters of this 
book. 



CHAPTER IY 
GENERAL THERAPEUTICS OF GYNECOLOGY 

General medication — Serum therapy — Local medication — Balneotherapy — Sugges- 
tion — Electricity — Massage. 

General Medication. — The lines along which modern gynecology 
has developed have been so distinctly surgical that relatively less 
attention has been given to the question of therapeutics. The error 
involved in this tendency is shown by the fact that the female genera- 
tive organs are in close vascular, nervous, and tissue, connection with 
the general system, of which they are as distinctly integral parts as are 
the eye, the ears, or other organs of special functions. They are capable 
of influencing and of being influenced by systemic states; and they 
are therefore, to a certain extent, amenable to therapeutic agencies. 
The medical aspect of gynecology is entitled to studious consideration. 
The deterioration of the blood, as manifested in the various anaemias, 
often finds expression in disturbance of the menstrual function; neu- 
rotic states not infrequently cause painful coition and dysmenorrhea, 
while hepatic disturbances produce pelvic hyperemias. It is appar- 
ent, therefore, that any therapy which will relieve the initial disturb- 
ance, will, to that degree, cure its results. This conception of the 
relation of the functional integrity of the genital organs to systemic 
states or to other anatomically remote diseases, must be the key to the 
intelligent employment of remedial agencies. Thus, a simple laxative 
may relieve ovarian tenderness, an active cholagogue may cure a con- 
gested uterus, and a course of iron and arsenic may become the most 
potent remedy for certain functional menstrual deficiencies. 

That remedies given by the stomach exercise in any important 
degree an elective action upon the nonpregnant uterus or its adnexa, 
is open to doubt. Ergot and the bromides, for example, given as rem- 
edies for uterine hyperplasia, have disappointed expectation. Laxa- 
tive agents, however, such as aloes and myrrh, which affect the lower 
alimentary canal, modify the functional activity of the generative 
organs by attracting an additional volume of circulation to the pelvis. 

The most valuable general remedy in the treatment of the diseases 
of women, is rest. This should be looked upon just as if it were a mate- 
rial agency, duly catalogued, and described in the materia medica. 

Eest in this sense implies not only physical repose, but, so far as 
possible, cessation from functional activity. To realize its full bene- 
20 



GENERAL THERAPEUTICS OF GYNECOLOGY 21 

fit, the marital relations of the patient should be for the time discon- 
tinued, and the patient herself should go to bed. That kind of rest 
which patients are prone to take by donning a loose gown and lounging 
here and there about the house, engaging in one activity after another, 
amounts practically to no rest at all. The practitioner will do well 
always to explain in minutest detail just what he means by rest when 
he prescribes it. In many of the minor acute inflammations, noninfec- 
tious in character, this remed}^ is alone sufficient to cure. 

Serum Therapy. — The treatment of gynecologic conditions by 
animal extracts was introduced by Jouin in 1895, and advocated in 
America by Polk (Medical News, January 11, 1899). The treatment of 
diseases of the uterus and adnexa by these agents is under advisement. 
Cures of amenorrhoea due to obesity are reported as resulting from their 
use. Polk has advocated the administration of thyroid extract for the 
cure of uterine fibroids, and has reported cases which seem to be im- 
proved by the remedy. The treatment seems to be based upon the well- 
known reciprocal trophic relationship existing between the uterus and 
the thyroid gland. This relationship has been emphasized by Freund 
{GentraTblatt fur Gynakohgie), who finds that swelling of the thyroid 
merely from congestion is always present in pregnancy, and also during 
menstruation. Wherever there is energetic or persistent irritation in- 
volving the uterine muscles, it will cause a persistent swelling of the 
thyroid. That this trophic impulse is derived from the uterus rather 
than from its adnexa, is shown by the fact that ovarian tumours and 
tubal dropsy do not cause enlargement of the thyroid, except when in 
rare instances they encroach upon and irritate the uterine muscle. 
These observations are in accord with those previously made by J. 
Fischer, who affirms and demonstrates not only the influence of the 
uterus upon the thyroid, but also that of the thyroid upon the 
uterus. YTomen with goitre generally suffer with menorrhagia and 
metrorrhagia; extirpation of the thyroid is followed by genital 
atrophy. Myxcedema in women is generally associated with amen- 
orrhoea. In cretins, there is a diminution and often an entire loss of 
sexual power. Menstrual disturbances are among the earliest symp- 
toms of exophthalmic goitre. These facts, long since established in 
America by Jenks, indicate beyond question the relationship existing 
between these two organs. It would seem that an extract made from 
the thyroid gland of the sheep and ingested into the human system 
exercises to some degree a modifying influence upon the uterus, its 
nutrition, and functions. The extent and exact character of this 
influence remain yet to be determined. Ovarian extract is given with 
the object of stimulating ovarian activity and of increasing the sexual 
appetite. Favourable reports of its use have been made, but whether 
the alleged results are due to physical or psychic influence remains to 
be determined. Protonuclein, locally applied, is unquestionably a 
valuable antistreptococcic agent, and reports are abundant indicating 
that it exercises a salutary influence over the nutrient activities. 



22 A TEXT-BOOK OF GYNECOLOGY 

Local Medication. — Local medication consists in the application of 
remedies directly to the part involved. This method of treatment is 
of great importance in many of the diseases which will hereafter be con- 
sidered. The application of escharotics to an inital syphlitic sore and 
the topical use of an antiseptic solution in the treatment of vaginal gon- 
orrhoea, are examples in point. Among the remedies thus employed for 
antiseptic purposes, the chief are mercuric bichloride, carbolic acid, 
lysol, creolin, and potassium permanganate. Among the local astrin- 
gents may be mentioned the salts of lead, zinc, and even iron. 
Boric adid is a favourite with many practitioners, while tannin is the 
vegetable salt of greatest importance in this class of cases. The action 
of astringents, all of which are to a certain extent antiseptic and ger- 
micidal, is to influence the circulation of the capillaries upon the 
tissues to which they are applied. They are frequently of question- 
able value, and always of less value than those agencies which have 
a more powerful influence in destroying the micro-organisms upon 
which depend practically all of the inflammatory diseases in the mucous 
and cutaneous areas. Hydrastinine, a comparatively new alkaloid, de- 
rived from the hydrastis canadensis, has been found by Falk to be a 
valuable astringent, when used in ten-per-cent solution locally, for the 
treatment of uterine hemorrhage. Sedative lotions and emollient 
applications are frequently demanded to relieve local distress in the 
external genitalia. 

Topical applications, having for their object the drainage of the pel- 
vis by exosmosis, should be employed in practically all cases of acute in- 
flammation, of chronic engorgement, or of persistent exudation within 
the pelvis. This treatment is made effective by virtue of the hygroscopic 
properties of glycerine. This agent has such powerful attraction for 
water that it abstracts it from any underlying tissue to the surface 
of which it is applied. This subject will be treated more in detail in 
connection with pelvic inflammations. 

Balneotherapy. — In no department of medical practice has the use 
of water proved of more value than in the management of intrapelvic 
diseases of women. Emmet, many years ago, pointed out the value of 
the vaginal douche and demonstrated its rationale — the water at a tem- 
perature varying from 105° F. to 120° F. is applied with the patient 
lying on her back, and continued for a period of twenty minutes at 
each seance. As has been demonstrated by Emmet, the primary influ- 
ence of the heat thus applied is to dilate the capillaries and to invite 
an increased supply of blood to the parts. In the course of ten min- 
utes, however, the secondary effect of the heat is realized. This is 
characterized by blanching of the parts, a contraction of the capil- 
laries, and a marked diminution in the volume of the local circula- 
tion. This treatment should be repeated at least twice daily. The 
results are invariably a marked amelioration of local engorgements, 
particularly when treatment is associated with rest and drainage by 
osmosis. Engelmann, of Kreuznach, has found general bathing 



GENERAL THERAPEUTICS OF GYNECOLOGY 23 

Tinder scientific supervision to be a remedy of great value. Asso- 
ciated with friction, it acts on the same principle as a counterirri- 
tant, attracting a considerable volume of the circulation to the surface, 
thereby relieving splanchnic congestions, and. by stimulating the nerv- 
ous system, becomes an active promoter of absorption. In this way it 
becomes valuable as a remedy for chronic exudates, adhesions, neo- 
plasms, and in the treatment of amenorrhcea due to obesity. It is 
contraindicated in acute inflammatory conditions. Engelmann says 
that an efficacious bath ought to contain from four to six pounds of 
common salt or sea salt, and also from two to five pints of mother lye to 
four hundred pints of water. The temperature of the bath should not 
exceed 95° F., and its duration should not exceed half an hour. The 
influence of such a bath is to calm the pulse and respiration and to 
induce sleep, which should always be encouraged. The better time for 
taking such a bath, therefore, is just before bedtime. 

Suggestion. — Suggestion as a therapeutic agent has been in vogue 
since the Pastaphori of Egypt practised it in the form of a " temple 
sleep," and ever since the healing by words was recorded in the Mosaic 
writings, or in the pages of the Zend-Avesta. It is based upon the 
influence of mental upon physical states, and while it has never re- 
ceived specific recognition as a distinct agency in gynecologic thera- 
peutics, it is nevertheless a remedy of unconscious daily application 
by every tactful practitioner. That uterine and other genital disturb- 
ances exercise a perturbing influence upon the mind is a matter of 
constant observation; and that the mind diverted from the seat of dis- 
comfort, or thoroughly impressed with the thought of and confidence in 
the recovery, thereby stimulates the organism in the direction of health, 
is a fact long known and practised by the profession. Suggestion may 
be carried not only to the unconsciousness of pain due to local physical 
disturbances, but to the degree of anaesthesia in parts that are not the 
seat of disease. So powerful is this agency that operations may be, 
and have been, performed painlessly under the hypnosis thus induced. 
An agent of such power should be subjected to more critical study 
than has yet been accorded it by the profession. (See Anaesthesia.) 

Electricity. — Electricity, in the form of faradism, is a remedy of 
some value when adminstered in such a way as to bring the nervous and 
muscular systems under its influence, when it acts as a promoter of 
metabolism and an important stimulant to the nutrient functions. Ad- 
ministered locally, under antiseptic precautions, with the negative pole 
in the uterus and the other upon the surface of the abdomen, it has 
been found to act as a stimulant in restoring the functional tone of that 
organ. With one pole in the vagina and another in the groin it has 
been found to relieve neuralgic conditions within the pelvis. Favour- 
able reports have been made of its use in catarrhal endometritis. There 
is no doubt that, judiciously applied, it promotes the growth of the 
undeveloped uterus, for which purpose the intrauterine electrode 
should be the negative one and that placed over the abdomen or over 



24 A TEXT-BOOK OF GYNECOLOGY 

the sacrum should be the positive one. It has been found to promote 
the absorption of effused products in the pelvis, but it must be recog- 
nised as a dangerous remedy in this class of cases, for the reason that 
it is practically impossible in many of them to determine when the 
exudation does or does not depend upon purulent infection, in the 
presence of which electricity should not be used. Electricity in the 
form of a strong current causes chemical decomposition of the tissues 
by the process of electrolysis, by which the acid elements are attracted 
to the positive pole and the basic elements are attracted to the negative 
pole. It was the application of this principle that induced Apostoli,. 
of Paris, in 1884, to attempt the disintegration and absorption of uter- 
ine fibroids by the use of strong electric currents. He began by using 
100, which he finally increased to 250 milliamperes, the strength of the 
current being accurately measured by a galvanometer. While, in many 
cases, this treatment temporarily arrested hemorrhage and diminished 
the size of the growth, its general results have not been accepted 
as satisfactory by the profession. It proved to be painful, causing, in 
many instances, deep eschars on the abdominal surface, intractable 
peritoneal adhesions, infections of the tumour, septicaemia, and, in 
some cases, death. 

Massage. — Massage is one of the most primitive of remedies, and is 
utilized by many aboriginal peoples. Stanley found it in use among the 
hordes of Africa; Stevenson found it in use among the Navajos; it was 
a remedy among the ancient Chinese and the Hindoos; and it was 
employed by the Greeks and Eomans. Hippocrates mentioned its use 
in diseases of the joints. In the great renaissance it appeared first in 
France, whence it spread to other European countries. Billroth, Es- 
march, von Mosetig, Thiersch, von Bergmann, von Mosengil, and others 
recommended it highly, first in diseased conditions of the extremities, 
and finally as a therapeutic measure in diseases of the internal organs. 
In the form of general massage it is a valuable remedy for the pro- 
motion of metabolism and elimination, especially in cases of the neu- 
rotic type. In these cases, judiciously applied, it tranquillizes the nerv- 
ous system, induces sleep, and, by virtue of its quality as a form of pas- 
sive exercise, it promotes nutrition. It is of special value as an adjunct 
to the " rest cure." For the realization of its greatest benefits it must 
be given scientifically, for the details of which the reader is referred 
to the various manuals on the subject. Massage is contraindicated in 
all febrile states and in the presence of acute inflammation. Dr. G-eorge 
H. Taylor has devised a method called by him vibratory massage, which 
is utilized by means of specially devised apparatus. The method shows 
great ingenuity and a scientific conception of the subject, and de- 
serves the most careful consideration. (See New York Medical Jour- 
nal, April 2, 1892.) 

Abdominal massage consists in the manipulation of the abdominal 
wall, and through it of the abdominal organs, for the purpose of pro- 
moting functional activity of the latter. As ordinarily employed, the 



GENERAL THERAPEUTICS OF GYNECOLOGY 25 

patient is placed in the recumbent posture with the abdominal walls 
flexed, when with the hand the abdomen is kneaded. This general 
exercise is supplemented by manipulations beginning in the right iliac 
fossse and extending upward to the hepatic flexure of the colon, thence 
across to the splenic flexure, and thence downward to the sigmoid, the 
object being to stimulate the colon to activity. As a substitute for a 
manual manipulation of the abdomen, Sahli places a cannon ball on the 
relaxed abdominal wall and rolls it around in various directions, and 
Ivanhoff has suggested a substitute in the form of a hollow wooden 
or celluloid globe, partially filled with shot. A shot-bag has been simi- 
larly used with excellent results. AYhen any one of these substitutes is 
used, its application should be concluded by rolling it repeatedly over 
the track of the colon from the caecum to the sigmoid. Abdominal 
massage, to be most effective, should be given half an hour before 
breakfast and repeated half an hour after breakfast. By its employ- 
ment the contents of the abdominal canal are moved onward, the 
portal circulation is accelerated, the lymphatics are given a fresh 
impetus, absorption and assimilation are promoted, the production of 
gas is diminished and its expulsion facilitated, and the splanchnic sym- 
pathetics are stimulated, while all the nutrient functions participate in 
the benefit. 

Pelvic massage has been popularized chiefly through the influence 
of Thure Brandt. It consists in the manipulation of the pelvic organs 
by the bimanual method with the object of correcting displacements, 
of curing old adhesions, of effecting the resorption of old exudates, of 
stretching shortened ligaments, and of reducing hyperplasias. The 
patient to whom it is to be applied is given a preliminary treatment 
of mild laxatives to unload the rectum, and boroglyceride tampons in 
the vagina to lessen pelvic engorgements. The patient is placed in the 
dorsal position with her knees well flexed; the vagina is thoroughly 
cleansed; the operator inserts the index finger of his "handy" hand, 
thoroughly oiled, into the vagina, passing it well up behind the cervix; 
the other hand is placed over the suprapubic region. At this juncture, 
and before any special manipulations are undertaken, a careful biman- 
ual examination of the pelvis should be made, a precaution which should 
be observed at the beginning of each seance. If points of recent 
engorgement or of especially acute sensitiveness are discovered the 
operator should desist. If, however, no such contraindications are 
found, it is prescribed, as the first movement of the massage, to 
press the external hand over and behind the fundus of the uterus, 
while slight downward traction is exerted by the tip of the intravaginal 
finger, the object being in all movements to ..draw the uterus gently 
toward the symphysis pubis. The ovaries are treated, when discover- 
able, by subjecting them to a similar range of mobility. Special move- 
ments are suggested by the particular conditions that may be discov- 
ered. A seance should not last over ten minutes, and the force to be 
employed, both in amount and direction, must be determined at the 



26 A TEXT-BOOK OF GYNECOLOGY 

time by the conditions encountered and by the judgment of the oper- 
ator. After massage a boroglyceride tampon is inserted, and if the 
manipulations have been at all painful the patient should remain in a 
state of repose for several hours. The dangers inherent in this method 
of treatment are so many that it has been largely abandoned by those 
who formerly employed it, while, on theoretic grounds, it has been 
perhaps too unqualifiedly condemned by those who have never tried it. 
Its chief danger consists in the fact that the exact diagnosis of intra- 
pelvic conditions is extremely difficult, and that consequently massage 
is liable to be employed with fatal results in conditions in which it is 
contraindicated. Among the accepted, but sometimes not recognisable, 
contraindications to the use of pelvic massage, are acute inflammatory 
processes; the presence of dilated Fallopian tubes; ovarian enlarge- 
ments; cystic degeneration in either the ovaries or the parovarium; and, 
above all, the presence of pus in the pelvis. (See Diagnosis of Pyo- 
salpinx.) 



CHAPTER V 
THE GYNECOLOGICAL ARMAMENTARIUM 

The more modern principles of treating wounds have led to marked 
modifications in the surgeon's armamentarium, and in no part, per- 
haps, has the change been so pronounced as in the kind of instruments 
used in operative work. The day of instruments with elaborately 
carved wooden and ivory handles is past, and complicated trocars and 
tubular needles no longer have a place in our instrument cases. The 
present tendency is to simplify their construction as much as possible 
and to use no greater variety than is absolutely necessary. The choice 
of instruments must necessarily vary with the predilections and train- 
ing of the individual operator. Certain main principles, however, 
should always be kept in mind. The surgeon need not encumber him- 
self with such instruments as are seldom needed, or with a multitude 
of so-called " surgical conveniences " and " automatic appliances." He 
should, however, always provide himself with a liberal supply of the 
instruments in common use, in order to be prepared for emergencies. 
None should be retained which do not permit of easy sterilization. 
Knives should have smooth metal handles, and handle and blade should 
be in one piece. Instruments with grooves, depressions, and notches, 
are to be avoided. Good hemostatic forceps with smooth blades can 
now be obtained, and are just as effectual as the old ones with grooved 
faces. All scissors, forceps, needle holders, and the like, should have 
simple articulations, so that the different parts are readily separable. 
An instrument with permanent joints can not be kept surgically clean, 
and should therefore not be tolerated. With our present methods of 
sterilization, instruments made of steel do not suffer as they did for- 
merly, and if properly cared for should not rust. Mckel plating has 
been proved to be not so valuable as was at first hoped, for, since instru- 
ments which are subjected to constant wear have soon to be replated, 
they would prove somewhat expensive. For those instruments which 
are but rarely used, however, nickel plating is advantageous, since it 
protects them from the action of the air. 

Instruments made of aluminum have been recommended, but they 
are undesirable for the following reasons: (1) They are too expensive; 
(2) they are too soft; (3) they will not stand repeated sterilization. 

In a hospital, one nurse or assistant should be given the full charge 
of the instruments, being held responsible for their proper sterilization 
and preservation. In private practice the surgeon must give the in- 

27 



28 A TEXT-BOOK OF GYNECOLOGY 

struments his personal attention; and even in hospitals he will do well 
to watch closely the assistant to whom they are intrusted, in order to 
be sure that the constant careful attention which is absolutely neces- 
sary is being paid to them. 

It is important to write out lists of instruments that are used in 
the different operations and to keep them where they can be easily 
consulted on each operation day, so that none which will be needed 
will be forgotten. Those lists should be divided into two parts, the 
first containing instruments which are sure to be required; the second, 
those that may possibly be needed under certain circumstances; they 
should therefore be prepared, although they may be set aside until 
they are called for. (For special lists of instruments, see the different 
operations.) 



CHAPTER VI 
DIAGNOSIS 

Definition and scope — Indications and contraindications for vaginal examination — 
The gynecological examination : Physical; the armamentarium ; the examina- 
tion itself; inspection of the external genitals; digital examination; bimanual 
examination; rectal exploration ; examination under anaesthesia; examination 
of the abdomen ; regions of the abdomen ; instrumental examination by (a) the 
speculum, (b) the sound, (c) the dilator, (d) the curette, (e) the aspirator — 
Examination of the secretions — Urine — Faeces — Menstrual discharge — The 
nervous system. 

The diagnosis of a gynecologic case consists in determining the 
character and location not only of the local disease, but of any asso- 
ciated pathologic states. The destructive character of many of the 
infections diseases and of both the benign and malignant neoplasms 
in women, and the essentially insidious onset of many of these condi- 
tions, render prompt examination and early diagnosis necessary for the 
welfare of the patient. This fact will be emphasized in discussing the 
diagnosis of individual diseases. To the end that diagnosis may be 
made early, it is the duty of the practitioner to impress upon his cli- 
entele the importance of this step, and that it may be made accurately, 
it is essential that he should take the broadest possible survey of the 
patient and make the most critical investigation of even suggestive 
departures from health. It is better, in an effort to avoid a narrow 
investigation of simply the conditions complained of, to leave the 
examination of the genital state until all essential facts in the patient's 
general history have been ascertained. To this end systematic inquiry 
should first be made relative to the patient's age, hereditary influences, 
menstrual and marital histories, previous diseases, and present com- 
plaints. While these interrogatories are being made and answered the 
physician should cultivate the habit of carefully noting the patient's 
appearance, with special reference to her nutrition, her nerve poise, 
and her temperamental characteristics. The pulse should be counted, 
the tongue should be inspected; in short, a general survey of the pa- 
tient should be made before strictly pelvic conditions are either in- 
quired into or examined. All of the facts thus gleaned should be re- 
corded and held in mind during the progress of the physical examina- 
tion, which should embrace the following steps: 

(a) The gynecological examination, including, if necessary, an ex- 
ploration of the bladder and rectum and inspection and palpation of 
the abdomen. 

29 



30 A TEXT-BOOK OF GYNECOLOGY 

(b) Special physical examination, including, according to the indi- 
cations of the case, inspection of the throat and upper air-passages, 
percussion and auscultation of the heart and lungs, ophthalmoscopic 
examination, etc. 

(c) Examination of the secretions — e. g., the urine, faeces, menstrual 
flow, and perspiration. 

(d) Examination of the blood. 

(e) Examination of the nervous system, with special reference to 
the determination of sensory and motor disturbances. 

Indications and Contraindications for Vaginal Examination. — In 
cases of girls and unmarried women a vaginal examination, either digi- 
tal or instrumental, should be undertaken only in the presence of posi- 
tive indications. Youth and virginity should always be looked upon 
as contraindications for such an exploration, unless in the presence of 
more than counterbalancing reasons: such, for instance, as the pres- 
ence of all the menstrual phenomena, the flow excepted, suggesting 
the possible retention of the menstrual fluid; or in the presence of 
an offensive discharge associated with remoter pelvic symptoms; or to 
investigate the origin of a persistent hemorrhage. There are numerous 
other conditions the importance of which will occur to the practitioner. 
It should be set down as a rule to which there are but few exceptions, 
that the examination of young girls in particular, and of many unmar- 
ried women of the nervous type, should be undertaken only under anaes- 
thesia. In this way alone can they be protected from a serious moral 
shock and more or less physical discomfort. When the examination 
is being made great care should be taken to preserve as far as possible 
all virginal conditions; but this consideration ought not to obtain to 
the point of defeating thoroughness of exploration in the presence of 
manifest necessity. 

In married women less hesitancy should be manifested in under- 
taking an examination, although even in such cases it should not be 
done for trivial reasons. When, however, there are either pudendal, 
vaginal, or high pelvic symptoms of an obscure character and suffi- 
ciently severe to justify treatment at all, the practitioner owes it both 
to himself and his patient to insist upon an examination. Any failure 
to take this stand is liable to be disastrous to both parties. 

In women past the menopause, all symptoms of a pelvic character 
should be regarded with suspicion and inquired into with promptness 
and precision. This is especially true in the presence of hemorrhage 
at or about the period of the change of life — a symptom which is 
nearly always an evidence of malignant disease. (See Menopause.) 

The Gynecological Examination. — It is as important in all gyneco- 
logical procedures to establish accuracy of diagnosis as in any other 
department of medicine. The responsibility of the gynecologist is not 
second in this respect to that of his confreres in the other branches of 
medical or surgical science. 

The foundation of correct diagnosis lies in the thoroughness of the 



DIAGNOSIS 31 

examination, and to this end every known means must be invoked in 
discovering the real seat of the malady and the character of its possible 
complications. 

At the initial consultation a complete history of the patient's con- 
dition should be obtained and accurately recorded. For this purpose 
it will be convenient to have a book so bound as to contain one hundred 
histories, and so ruled and spaced that additional entries may be made 
at subsequent dates. It is a good -plan to have the history blanks 
printed in sheets that may be filed temporarily and be bound after an 
adequate number have been filled. 

The form of the blank can be devised by each physician according 
to his own preferences, hence it is only necessary here to call attention 
to the essential points of the record. These are — after entering the 
name, age, social condition, address, and other preliminary data — to 
record the family history as bearing on heredity; the menstrual history; 
the number of children borne and the character of the labours; mis- 
carriages and their sequela?; condition of bowels and bladder as to func- 
tion; all pelvic phenomena that are abnormal; and, finally, every fact 
pertaining to the special condition for which the consultation is sought* 
After the physical examination has been made, all lesions, growths, or 
abnormities should be carefully entered, and the treatment advised or 
instituted, set forth in detail. Each physician, as he becomes impressed 
with the value that attaches to accuracy, will record all data shown by 
experience to be important. The foregoing are merely suggestive, and 
are, moreover, such as may not. in any case, be omitted. 

Physical Examination. — After having made and recorded an oral 
examination of the patient, the next step involves a physical investiga- 
tion by inspection, palpation, and pelvic exploration. The events 
under consideration in these pages are made applicable to office con- 
sultations, hence details are given adapted to that environment. Suit- 
able rooms are requisite, and should number three or more, en suite — 
one a reception room, another a consulting room, and a third solely 
used for the examination. In this last there should be running water, 
hot and cold, and a toilet room adjoining is well-nigh a necessity. The 
examining and toilet rooms should be presided over by a comely woman, 
trained as an office assistant. She need not necessarily be a nurse, but 
she should be a trustworthy woman competent to hold a speculum 
and intelligent in all that pertains to gynecological work. 

The armamentarium should consist of a table, specula, dressing 
forceps and tenacula, douche apparatus, absorbent cotton and antisep- 
tic wool, sounds and applicators, lubricant, protective or pad, sheet, 
and gown. 

The table should be strong and should stand solidly on its four 
legs. It should be capable of extension to enable the patient to lie 
in the horizontal position, reasons for which will be considered pres- 
ently. It need not necessarily be an expensive or complicated affair, 
but should be equipped with foot rests, a thin mattress, and pillows. 



32 A TEXT-BOOK OF GYNECOLOGY 

An assortment of Sims's specula are essential, and one or two good 
bivalves will be convenient. 

Every successful gynecologist knows the value of the Sims specu- 
lum, and every one who expects to practise the specialty must of neces- 
sity make himself familiar with its uses. The objection often made to 
it is that a competent person is required to hold it. If the beginner 
can not employ such a person, then he must provide himself with one 
of the so-called self-retaining Sims instruments. Potter prefers the 
Emmet self-retaining attachment for this purpose. It is the simplest 
and can be held easily by the patient, who will grasp a piece of rubber 
tubing passed through the fenestrum of the buttock blade. 

Sounds and applicators are included in the office outfit, but it is 
proper to remark that they seldom will be needed. The indiscriminate 
use of the sound has proved harmful to many women, and should 
never be used by unskilful hands. Nevertheless it will occasionally 
be serviceable as an aid to diagnosis, hence is included in the list. 
Applicators, too, will rarely be employed. We need not enter into a 
discussion of the propriety of topical applications to the endometrium, 
but it will suffice to say that as a routine it is of doubtful propriety. 
Occasionally, however, such treatment is needful, hence the instru- 
ments must be at hand. 

The selection of a proper lubricant is a matter of considerable im- 
portance. A^aseline is in common use, but it is not easily removed 
from the hands. Dudley (Diseases of Women, second edition, Lea 
Brothers & Co., 1900) prefers glycerine, which is cleanly, sterile, but 
expensive. Some are partial to glymol, certainly an excellent agent. 
Potter recommends alboline in collapsible tubes, which is thus kept 
germ free, is cheap, and efficient. 

The so-called Kelly pad, really a device of Joseph Price, is a con- 
venient protective, but it, too, is expensive, and besides is difficult to 
keep clean. A piece of rubber sheeting will answer every purpose, pro- 
vided that it is rolled at the sides and back to prevent backflow of 
water. 

A douche apparatus should be at command for all office examina- 
tions or treatment. It should consist of a reservoir that will hold at 
least a gallon of sterilized water, with rubber tubing attached to a 
vaginal douche nozzle with backflow arrangement, and the tubing 
should be equipped with a gate or cut-off. Before examination the 
woman should be divested of unnecessary clothing, such as corsets and 
superfluous skirts, then placed upon the table in the dorsal posture, 
with feet in the foot rests, and the pad or protective properly adjusted 
to prevent wetting or soiling the clothing. After covering her with 
a sheet, the douche may be administered. This should consist of an 
appropriate quantity of sterilized water at a temperature of about 115° 
F. If there is suspicion of infection, the douche should be rendered 
antiseptic by the addition of bichloride of mercury sufficient to make 
a solution of 1 to 2,000. 



DIAGNOSIS 



33 




Fig. 1. — " The woman is now placed upon the table, 
usually in the dorsal position." — Potter. 



The Examination. — The preparation of the patient may be made 
by the office assistant, who, as we have said, should be a competent 

woman. She shonld ar- 
range the clothing of the 
patient, administer the 
donche, and, if need be, 
give an enema to nnload 
the rectum. This latter 
is important if there is 
constipation, as a distend- 
ed lower bowel may mis- 
lead in diagnosis. Such a 
condition not only dis- 
places the pelvic viscera, 
but it may be mistaken 
for a tumour, new growth, 
or retroverted uterus. Af- 
ter these preliminaries the 
patient is ready for the examination proper, which, it is almost needless 
to add, in these days of asepsis, should be conducted with the utmost 
aseptic care. 

The examiner himself should prepare his hands as carefully as if 
he were about to conduct an abdominal section or other important 
surgical operation. His lavatory should be supplied with the best of 
soap. A number of nail brushes, too, should be at hand, and of these 
there is none better, or indeed so good, as those made of vegetable 
fibre. They are cheap, durable, and can be kept clean. 

We have already alluded to the administration of the douche, which 
should invariably precede the examination unless for some special rea- 
son it becomes necessary to inspect the uterine, vaginal, and vulvar 
fields, to study their 
secretions or exudates 
with a view to deter- 
mine their character, 
in the expectation that 
they may furnish an 
important aid to diag- 
nosis. But when it 
is used, particular care 
must be paid at the 
conclusion of the ex- 
amination to the dis- 
infection of the douche nozzle as well as of the hands of the physician 
and assistant and of all else that comes in contact with the patient. 

With these preliminaries the woman is now placed upon the table, 
usually in the dorsal position (Fig. 1), as already indicated; or, accord- 
ing to the requirements of the case or the preference of the operator, 
4 




Fig. 2.— " . . . Or, according to the requirements of the case, 
or the preferences of the operator, she is placed in the 
left lateral prone, better known as Sims's posture." — 
Potter (page 34). 



34: 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 3. — " . . . Which is better appreciated if studied 
from the foot of the table." — Potter. 



she is placed in the left lateral prone, better known as Sims's, posture 
(Fig. 2), which is better appreciated if studied from the foot of the table 
(Fig. 3). Occasionally it will become necessary to employ the knee- 
chest posture (Fig. 4), and sometimes a woman should be examined 
while she is standing (Fig. 5). 

Upon mounting the table, the woman should sit upon the end of it, 
which should be properly covered with protective and aseptic towels. 

A pillow should be provided 
for her head, but, as she is 
to lie flat upon her back, the 
shoulders should not be ele- 
vated by the pillow. A sheet 
or other proper covering 
should be spread upon her 
lap while she is yet sitting 
on the end of the table. She 
is now assisted to lie down, 
the nurse taking hold of her 
feet and placing her heels in 
the stirrups, which should 
be placed as close together as possible and which have been drawn out 
to receive them. The thighs thus become flexed, the abdominal mus- 
cles relaxed, and the knees Avidely separated. In a first examination 
it will often become necessary to assure the patient that she is neither 
to be hurt nor exposed, after which the covering may be parted and 
adjusted around the vulva, which is ready for inspection. 

Inspection of the External Genitals. — It becomes necessary, espe- 
cially with a strange patient, at a first examination to inspect the vulvar 
field with care. This is done, not only for diagnostic reasons, but for 
safety. A physician may become infected from a venereal sore, even 
on the person of an inno- 
cent woman, unless the 
presence of such a le- 
sion is detected before- 
hand. To be forewarned 
is to be forearmed. In 
the investigation of such 
a case, abrasions of the 
hand, and especially of the 
examining finger, should 
be painted with collodion. 
Having determined 
the nature of the secre- 
tions of the parts, and 
having carefully inspected the hymeneal orifice, noting whether the 
hymen has been ruptured, the examiner should next look carefully 
for the evidences of parturition — such as lacerations, cicatrices, and the 




Fig. 4, 



-" Occasionally it will become necessary to em- 
ploy the knee-chest posture." — Potter. 



DIAGNOSIS 



35 



like — and then he may look for tumours, urethral caruncles, vulvitis, 
urethritis, eruptions, ulcerations, cystocele, rectocele, inflammations of 
Bartholin's and Skene's glands, oedema, and pruritus. The rectum 
should be explored with reference to hemorrhoids, fissure, fistula in ano, 
pimvorms, and any anomaly of anatomic configuration. The clitoris 
should be examined with reference to any enlargement or an adherent 
prepuce. The vulvar orifice, if capacious or gaping, gives token at least 
of marital relations, whereas the virgin vulvar orifice is small, com- 
pact, with a more or less perfect hymen. The absence, however, of the 
hymen is not considered evidence of unchastity — a fact that should 
always be kept uppermost in the mind of the gynecologist, especially 
in the commencement of his practice. 
The condition of the labia minora should 
also be noted. When these are long, flab- 
by, and pendulous in contour, it is prob- 
able that the woman is a masturbator. 
This condition of the minor labia, it is 
quite true, might arise from other causes, 
but this is the most probable explanation 
of it. 

While inspection is usually limited to 
the region and for the purposes named, it 
may be carried upward to include the 
surface of the abdomen, whereby enlarge- 
ment or imperfection of contour may be 
discovered. Inspection of the interior of 
the vagina through the speculum, and of 
the rectum by a similar instrument, does 
not come within the limit of this section, 
but will be described under its appropriate 
head. 

Digital Examination. — By far the most 
important method of investigation is the 
examination by the fingers and hands. 
The tactile sense is so acute, and may be 
so highly educated, as to supersede or take the place of every other 
method, provided one were limited to a single means of obtaining 
information. It becomes of the first importance, therefore, that 
it shall be employed intelligently, systematically, and thoroughly. 
We shall not enter into an argument as to whether the right or 
left index finger is the better for this investigation, but shall con- 
tent ourselves with saying that while the specialist will frequently 
prefer the left, and most of such at least will be ambidextrous, the 
general practitioner will usually employ his right finger or fingers for 
the digital examination. An advantage in using the left finger is that 
it leaves the right hand free for instrumental use and for bimanual 
examination. Again, it preserves the right hand from the clanger 




Fig. 5.—". . . Sometimes a woman 
should be examined while she 
is standing." — Potter (page 34). 



36 A TEXT-BOOK OF GYNECOLOGY 

of becoming an infection carrier, which is perhaps a matter of con- 
siderable moment in dispensary or hospital work. Sometimes it will 
be useful to employ two fingers in the investigation, but this will be 
rather the exception than the rule, limited to the capacious vagina 
and the short index finger. Two fingers in a narrow vagina are, to say 
the least, painful; but, as the index finger is sometimes short and the 
diagnostic reach can be increased perhaps half an inch by the con- 
joined use of the index and ring fingers, this expedient occasionally 
becomes not only justifiable but useful. 

There is nothing that indicates greater gynecological skill than 
the tactful employment of the digital examination. The clumsy, hasty, 
and rough manner, in which it is sometimes used, is to be strongly 
condemned. On the other hand, it should be employed with the great- 
est delicacy, but at the same time with thoroughness, precision, and 
aptitude. Every gynecologist should avail himself of every oppor- 
tunity to educate his finger tips; indeed, they should be brought to that 
degree of tactile perfection that a reasonable degree of accuracy in 
diagnosis can be obtained, in the majority of cases, without an appeal 
to instrumental aid. The digital examination becomes available and 
applicable in the horizontal, dorso-sacral, latero-prone, genu-pectoral, 
and standing, postures. But its chief application is in the dorsal or 
dorso-sacral postures. Finally, the index finger occasionally becomes of 
great usefulness in everting the anus by pressure through the vagina 
upon its posterior wall. In this manner the examiner will often detect 
with ease and precision rectal or anal faults that otherwise might re- 
main obscure. 

It remains for us to give the technique of the digital examination. 
To begin with, let us repeat, the toilet of the hands, and especially of 
the index finger to be employed, should be most carefully made. Thor- 
ough washing with soap and warm water and scrubbing with the nail 
brush should precede the lubrication. Then the finger tip, palmar 
surface downward, should be carefully passed into the vagina against 
its posterior wall, the fingers of the other hand being used to separate 
the labia and to slightly distend the vulvar orifice. In this manner 
it will note, first, the condition of the perineum, its rigidity or laxness, 
its integrity or imperfectness; secondly, the condition of the rectum, 
whether it contains faeces or is empty; thirdly, the relation of the coccyx 
to the pelvic outlet; and fourthly, the capaciousness or narrowness of 
the vagina. Turning now the finger upward and passing from side to 
side along the vagina, its lateral surfaces are explored, until finally 
the cervix uteri is reached. Here is an important field for investi- 
gation. If the cervix is soft, like the lips, a suspicion of preg- 
nancy will arise; if firm or hard, like the nose, such suspicion will 
be dispelled. The cervix and os must now be carefully examined with 
reference to size and form and direction of the cervix, and the pres- 
ence or absence of lacerations or new growths in the os. The im- 
portance of thoroughness with reference to this portion of the exami- 



DIAGNOSIS 



37 



nation is to be insisted upon, and an educated finger tip is essential 
to its completeness. 

Bimanual Examination. — A great advance in the diagnosis of pel- 
vic diseases was signalized by the introduction of the bimanual method 
of investigation (Fig. 6). The term may be defined as the examina- 
tion of the pelvic contents by the two hands, the index finger of 
one being in the vagina and the other placed on the abdomen above 
and beyond the pubes with which to make downward pressure. The 
finger within the vagina lifts up the organ or organs, and the finger tip 
of the other hand pressing downward upon the relaxed abdominal walls 




Fig. 



A great advance in the diagnosis of pelvic disease was signalized by the introduc- 
tion of the bimanual method of examination.'' — Pottek. 



engages it or them between the two. Beginning first with the bladder, 
its sensitiveness, distention, or emptiness, is noted. Passing upward 
to the uterus, its size, condition as to firmness or softness, and its posi- 
tion, whether in anteflexion, retroflexion, or prolapsus, is determined. 
Here, again, the first question upon the mind is that of possible preg- 
nancy. If in the digital examination a soft cervix has been felt, the 
inquiry as to pregnancy must be pursued bimanually, and if it is 
learned that the uterus is enlarged and has floating contents the sus- 
picion will be confirmed, and further examination should be postponed 
until the question is determined. It is important to deal with this sub- 



38 A TEXT-BOOK OF GYNECOLOGY 

ject first, because, in case pregnancy exists, it stands in the way of any 
further pelvic exploration lest abortion be induced. An exception to 
this rule would be when tumours or new growths coexisted with sup- 
posed pregnancy or complicated each other in an already diagnosticated 
condition. Then, if there is some technical point to determine, the 
bimanual examination may be cautiously further pursued. 

Displacements of the uterus are most easily and certainly diag- 
nosticated by means of the bimanual examination. The normal posi- 
tion of the uterus, it will be remembered, is one of moderate ante- 
flexion, in which a line drawn through its long axis appears at the 
umbilicus; with the fundus, however, lying farther forward, compress- 
ing the bladder and impinging on the pubes, the uterine body will be 
easily engaged and mapped out between the two hands. It will, how- 
ever, require some experience to distinguish between anteversion and 
anteflexion — all of which will be properly set forth by another writer 
under its appropriate head. Eetrodisplacement of the uterus may also 
be determined by feeling the fundus resting against the rectum in the 
sacral excavation, and by its absence from its appointed place as ascer- 
tained by pressure of the external hand. The cervix, too, in retrover- 
sion, will be carried upward and forward toward the pubic arch, thus 
resting the entire organ horizontally across the pelvis at right angles 
to the normal direction of the vagina. Here, again, some nicety of 
touch, which a little experience may soon acquire, is required to de- 
termine between retroversion and retroflexion. Prolapse of the uterus 
is more easily determined, since the index finger will come in contact 
with the cervix just within the vulvar orifice, or a little higher up, 
according to its degree. Procidentia will readily be discovered upon 
inspection, since the organ in whole or in part protrudes from the 
vagina. 

One of the most important functions of the bimanual is to ascer- 
tain the condition of the tubes and ovaries. An experienced examiner 
will readily discover whether the tubes are enlarged, pulpy, and soft or 
hardened, and whether the ovaries are unduly tender and sensitive, 
enlarged or atrophied, displaced, or the seat of new growths. An en- 
larged pulpy tube, sausagelike in shape, is suggestive of hydrosalpinx 
or pyosalpinx. At any rate, it means a diseased condition, which an 
accurate history combined with careful bimanual palpation will usually 
distinguish. The broad ligaments should also be carefully inter- 
rogated as to whether new growths lurk within their folds and if they 
properly support the uterus and adnexa. Adhesions, too, should be 
sought for, and if found, Avili of necessity influence further investiga- 
tion and treatment. If the uterus and its appendages are tender, bound 
down by adhesions, or if there is an abscess or pus tube, great caution 
must be exercised in pursuing further investigation. It would be in- 
excusable to rupture such a pus container, or to set up further inflam- 
matory processes by the use of force in the bimanual, or through a re- 
sort to instrumentation. 



DIAGNOSIS 39 

It will be readily understood from the foregoing that the proper 
exercise of the bimanual in order to attain its greatest possibilities re- 
quires an experience that only long practice can give; hence, the be- 
ginner should never miss the opportunity of employing it under the 
supervision of a competent instructor. Only in this way can he learn 
either to bring the organs properly within reach, or to appreciate what 
he feels between his hands. 

At the outset he will often be foiled in his efforts by the nervous- 
ness of the patient; this he must overcome by his tact and gentleness, 
always giving the impression that he is thoroughly at home in his 
work. If he betrays his inexperience by suddenness of movement, inex- 
actitude of touch, or other evidences of the novitiate, his usefulness 
will be limited or destroyed. Complete muscular relaxation on the 
part of the patient must be obtained, and great self-possession by the 
examiner must exist. These two factors are conditions precedent to 
success. 

It is well to remember in pursuing the bimanual method, espe- 
cially when it becomes necessary to make upward pressure upon the 
vulvar orifice in order to reach high up in the pelvic cavity, that some- 
times sensitive or passionate women may be incited to sexual orgasm 
from irritation of the clitoris; hence, contact with that organ should 
be avoided as far as possible. It is probable that the aggregate number 
of such patients is very inconsiderable, because illness, and especially 
disorders of the pelvic organs, diminish the tendency to sexual excite- 
ment arising from physical exploration of the genital tract. Its possi- 
bility, however, should not be forgotten. 

To recapitulate, the information to be derived from the bimanual 
method of examination may be grouped as follows: 

First, capacity, rigidity, and tonicity, of the vagina. 

Secondly, as to pregnancy, pro or con. 

Thirdly, the condition of the bladder and its relation to the other 
pelvic organs. 

Fourthly, the uterus, its size, position, presence or absence of 
tumours within its walls, and the condition of the cervix as to integrity 
or lacerations. 

Fifthly, the status of the tubes and ovaries as to size,' location, and 
relationship to neighbouring parts. 

Sixthly, the condition of the rectum as to faecal impaction or disease 
of any kind, such as fistula, fissure, cancer, or hemorrhoids. 

Seventhly, as to the presence of any abdominal or pelvic tumour, 
new growth, extra-uterine pregnancy, or any abnormal condition not 
embraced in the foregoing classification. 

Finally, it may be remarked that in the case of tumours the biman- 
ual affords opportunity to distinguish between cystic and solid growths, 
and, to a certain extent, between benign and malignant neoplasms. 

Rectal Exploration. — It remains for us to describe examination by 
the rectum, which oftentimes becomes an important adjunct to the 



40 A TEXT-BOOK OF GYNECOLOGY 

examination. The index finger in the rectum will sometimes serve to 
clear up a doubt or detect a hitherto undiscovered condition. It will 
help to diagnosticate a retroverted womb or to distinguish between that 
displacement and a post-mural fibroid growth. Again, it will serve 
to locate a hitherto undiscovered ovary occupying Douglas's pouch. 
Still again, examination per rectum may detect disease in that organ 
which will explain symptoms that otherwise would have been misun- 
derstood. In all cases in which careful vaginal bimanual fails to dis- 
cover disorder adequate to explain symptoms or to suggest a diagnosis, 
rectal exploration should be made. This procedure is often disagree- 
able, if not painful, to the patient, hence, must be instituted with great 
delicacy and only after thorough lubrication of the examining finger 
as well as the anal orifice. External hemorrhoids, even if inactive, will 
further emphasize the importance of careful preliminaries to the ex- 
ploration. (See Examination of the Rectum.) 

Examination under Anaesthesia. — Finally, when all the ordinary 
means fail to overcome the nervousness of the patient, the rigidity of 
the abdominal muscles, or other hindrances to the thorough and intel- 
ligent employment of the bimanual method of examination, anaesthesia 
may be appealed to; indeed, with the full consent of the patient and 
with adequate assistance it should be resorted to as an important ele- 
ment in leading to correct diagnosis. 

Examination by this means should be carefully conducted with 
reference both to its advantages and its dangers. Its advantages con- 
sist in overcoming hypersensibilities, both mental and physical, and in 
eliminating involuntary muscular resistance as a barrier to successful 
manipulation. By this means it is possible to explore with approximate 
accuracy the entire peritoneal surface of the uterus, both anterior and 
posterior. The ovaries and Fallopian tubes can be palpated; the 
presence and absence of intrapelvic tumours, including cysts, myomata, 
nodes, etc., can be determined. The presence or absence of adhesions 
can often be decided. The disadvantages of anaesthesia in gyneco- 
logical examinations centre chiefly in the elimination of pain, which of 
itself possesses great diagnostic value, and is also a safeguard against 
injudicious and dangerous manipulation. It may be laid down as a 
rule, therefore, that anaesthesia for purposes of examination is dan- 
gerous in the presence of a degree of sensibility indicative of acute 
inflammation. 

Auscultation, Percussion, and General Palpation of the Abdomen. — 
Of diagnostic measures, auscultation, percussion, and palpation, can 
be applied to the recognition and diagnosis of pelvic and abdom- 
inal tumours, inflammatory residues, and diseases of the appendi- 
ceal region, kidneys, spleen, liver, and gastro-intestinal tract. The 
method of applying these aids to diagnosis will be readily suggested to 
the examiner. Palpation of the kidney becomes important in relation 
to the diagnosis of diseases of that organ, and occasionally, also, in 
distinguishing between abdominal tumours and movable and so-called 



DIAGNOSIS 



41 



RIGHT 

UPPER 
QUADRANT 



LEFT 
UPPER 
QUADRANT 



floating kidney. A movable kidney, which would escape the casual or 
indifferent observer, is often detected by a careful diagnostician. Hy- 
dronephrosis has been confounded with ovarian and other cysts. A 
detailed description of the diagnosis of kidney diseases is foreign to 
the purpose of this chapter, and the reader is referred to the section 
which deals with that subject. In examining the abdomen it is highly 
important, not only to hold in mind the locus of each of its contained 
organs, but to have an accurate conception of its regional arrangement. 
Regions of the Abdomen. — It has been customary heretofore to 
divide the abdomen anteriorly into nine different regions as a con- 
venient means of des- 
ignating either the lo- 
cation of symptoms or 
operations, or of the 
presumably underly- 
ing organs and struc- 
tures. This division, 
however, has proved 
unsatisfactory, because 
of the cumbersome- 
ness of its terminol- 
ogy, the narrowness 
of the areas indicated, 
the indefiniteness of 
the imaginary lines of 
division, and the ana- 
tomical variations in 
the location of their 
supposed underlying 
organs and structures. 
In accordance with 
the suggestion of Pro- 
fessor Anderson to 
the Anatomical Socie- 
ty of Great Britain 
(Buffalo Medical and 
Surgical Jour., 1893), 
these objections are 
best obviated by divid- 
ing the abdomen into four regions. This is done by running a line 
coincidently with the linea alba from the symphysis pubis to the ensi- 
form cartilage, and another at right angles to this at the level of the 
umbilicus and encircling the entire body. The median line posteriorly 
is indicated by the spinal column. This arrangement, which is based 
upon definite landmarks, and divides the abdomen into four quadrants 
(Fig. 7) — namely, right and left, upper and lower — will be observed in 
the following pages. 



RIGHT 


LEFT 


LOWER 


LOWER 


QUADRANT 


QUADRANT 




Fig. 



7. — u This arrangement, based upon definite landmarks, 
divides the abdomen into four quadrants." — Reed. 



42 



A TEXT-BOOK OF GYNECOLOGY 




Instrumental Examination. — A most important adjunct to methods 
of diagnosis is furnished in the marvellous development of mechanical 

instruments and appliances. The inge- 
nuity of physicians and instrument 
makers has presented to the gynecologist 
an enormous collection from which to 
choose. The armamentarium, however, 
should be simple, and such instruments 
as are chosen should be models of per- 
fection. It should never be forgotten, 
also, that instrumentation, no matter how 
dexterously applied, can never be made 
to supplant the educated hands and finger 
tips. Instruments at most are supple- 
mentary aids to these. We may, how- 
ever, enumerate some of the instruments 
which are considered a necessity by the 
gynecologist. These are: (1) The specu- 
lum, (2) the sound or probe, (3) the dila- 
tor, (4) the curette, (5) the cystoscope, 

(6) the aspirator with exploratory needles, 

(7) the stethoscope, (8) the uterine dress- 
ing forceps, (9) the spatula or depressor, 
(10) the tenaculum, (11) the volsella. 

The Speculum as a Means of Ex- 
amination. — Since Sims gave to the 
profession the speculum which bears his name the practice of gyne- 
cology has become an established specialty. Without this device it is 
doubtful if gynecology could have been enlarged, broadened, and devel- 
oped into the importance which it has attained at the present day. 
Dr. J. Marion Sims, then residing in the city of Montgomery, Ala., was 
engaged between the years 1845 and 1849 in the study of the opera- 
tive treatment of vesico-vaginal fistula. During his investigations he 
accidentally discovered that if a woman was placed upon her knees 
and chest, upon separating the labia the air would enter the vagina and 
distend it to its full capacity. What was needed was an instrument to 
retract the perineum. This he supplied first with a spoon handle bent 
to the appropriate shape, and afterward, as the product of evolution, 
came the present speculum, which universally bears the name of Sims 
(Fig. 8). In the further pursuit of his investigations, and for the ap- 
propriate use of his speculum, a less trying posture was needed than the 
knee-chest. This led to further experimentation from which was 
evolved the semiprone, or Sims's, position. It is sometimes called the 
latero-prone posture, but, by whatever name it is known, its discovery 
and practical application are due to Marion Sims. The Sims speculum 
and the Sims position form the basis of the science of gynecology as at 
present understood and practised. Whoever, then, would attain suc- 



Fig. 8. — ". . . Speculum, which uni- 
versally bears the name of Sims." 
— Potter. 



DIAGNOSIS 



43 



cess in the art, mast not only familiarize himself with the principles of 
this instrument and its correlative posture, but he must acqure deftness 
in their practical application to the patients who consult him. 

The beginner, therefore, should address himself to the mastery of 
the use of the Sims speculum in the semiprone or Sims posture. 
The principles are simple and the obstacles to be overcome are few. 
It is a mistake to suppose that a long experience is necessary to attain 
proficiency in the use of the speculum. It is another mistake to pre- 
sume that a trained assistant is necessary to its advantageous employ- 
ment. The physician himself must be the expert; he can then easily 
instruct any intelligent person to hold the speculum properly. These 
examinations, for obvious reasons, should be conducted in the presence 
of a third person. A gynecologist of large practice has an office assist- 
ant who performs this service. A physician whose gynecological prac- 
tice is limited may either avail himself of some member of his house- 
hold in office examinations or employ the Sims-Emmet self-retaining 
speculum, which has already been referred to (page 32, q. v.). In 
making examinations at the home of the patient the aid of some mem- 
ber of her family may be invoked; and this brings us to make mention 
of home examinations. 

In order to make these examinations satisfactorily and to obtain 
adequate information from them, the same conditions must prevail as 
in the consulting room. The 
patient must be placed upon a 
table, the douche must be ad- 
ministered, and the bimanual or 
instrumental examination is to 
be proceeded with, with the same 
attention to detail. Whenever 
the attempt is made to use the 
bed or couch dissatisfaction will 
result. It is, comparatively speak- 
ing, little trouble to make the 
home examination in the proper 
manner. The humblest home is 
furnished with a four -legged 
table; this can be covered with 
blanket, sheet, and protective; 
the fountain syringe can be hung 
on a nail near by, and if an in- 
strumental examination is need- 
ful a Sims-Emmet self-retaining 
speculum can be employed. Or, 
failing in the possession of this, 
the ordinary Sims instrument can 
be used, and an assistant to hold it may be pressed into service from 
the household or neighbourhood. 




Fig. 9. — u A good bivalve like Gau\s. 
— Potter (page 44). 



44 



A TEXT-BOOK OP GYNECOLOGY 




Before leaving the subject 
of the speculum it is proper to 
state that the essential re- 
quirements for the success- 
ful use of the Sims instru- 
ment are, first, the correct 
position of the patient; and, 
secondly, the proper hold- 
ing of the instrument. The 
semiprone posture can not 
be described in words with 
sufficient clearness for a nov- 
ice to understand it; more- 
over, it is difficult to illus- 
trate it clearly, hence it is 
advised that a physician un- 
familiar with it should place 
himself under the instructions 
of a person who understands 
it thoroughly. 

Besides the Sims specu- 
lum, it is well to have at 
hand a good bivalve, like 
Miller's or Gail's (Fig. 9), 
which gives a good view of 
the cervix (Fig. 10), as well 
as a tri valve, the latter according to Nott's model (Fig. 11). It occasion- 
ally becomes necessary to examine the os or cervix uteri in the dorsal 
position, and these specula are well adapted to that purpose. (See 
Armamentarium.) 

In the use of the specu- 
lum it is sometimes desira- 
ble to use reflected light 
or the intense rays of an 
electric illuminator. In 
cases of erosion of various 
character, material assist- 
ance in diagnosis may be 
derived from the use of 
a magnifying glass, like 
that devised for the pur- 
pose by Dr. Alexander 
Duke, of Cheltenham 
(Medical Press and Circu- 
lar, May 15, 1900). The 
lens, called a hysteroscope, is so arranged on a hinge that it can be 
placed at an angle by the observer. By this means the light can be di- 



Fig. 10. 



Which gives a good view of the 
cervix." — Potter. 




DIAGNOSIS 



45 



rected with accuracy upon the parts under examination, and when used 
with artificial light it acts both as a condenser and a magnifier (Fig. 12). 
The Sound as a Means of Examination. — Formerly the sound was 
considered an essential part of the gynecological armamentarium, be- 
cause almost the first thing done after the in- 
troduction of the speculum was to pass the sound 
into the uterus. Nowadays, however, with improved 
methods of diagnosis, and especially through a more 
thorough understanding of the bimanual, the sound 
rarely is Deeded. Its chief purpose is to confirm the diagno- 
sis in doubtful cases, such as intrauterine 
growths and other intrapelvic abnormalities 
that are misleading in their character. The 
dangers of the sound consist in its liability to 
carry infection within the genital tract, and 
to puncture the uterine wall; the latter is, 
comparatively speaking, an inconsiderable 
danger, whereas the former is a very grave 
one. The sound devised by J. F. AY. Eoss 
(Fig. 13) is best designed to obviate all dan- 
gers. The sound is no longer used by the 
experienced gynecologist to reposit a dis- 
placed womb, and whenever it becomes 
necessary to use it as an aid to diagnosis, 
first, it should be made thoroughly aseptic. 
and then it should be dipped in pure car- 
bolic acid rendered liquid by the addition of 
five per cent of glycerine, before it is passed 
into the uterus. With this precaution, and 
with gentleness in manipulation, the sound 
may not do harm, and possibly it may serve 
to clear up a doubtful diagnosis. The probe 
is only a modified sound, lighter in con- 
struction, and much more flexible, and prac- 
tically is used for the same purpose. Appli- 
cators, either of whalebone or aluminum, are 
useful in carrying certain medicinal applica- 
tions within the uterine canal. If, however, 
the uterus is sensitive from inflammation, the use of the 
sound, probe, or applicator, is contraindicated, although 
in some instances where information is urgently needed 
a very light probe might possibly be introduced without 
harm. The rule should be never to pass the sound or 
probe unless it can be used without causing pain. 

The Dilator as a Means of Examination. — Dilatation -The sound de- 
of the uterus is accomplished by graduated bougies, by vised by J. F. 
metal dilators having divergent blades, by tents, or by p ' TT er^' 



Fig. 12. 

" The lens called 
a hysteroseope." 
— Potter. 



46 



A TEXT-BOOK OF GYNECOLOGY 



rubber bags to be filled with air or water. The usual method is 
through the medium of the hard-rubber graduated bougie or the 
mechanical steel dilator of Goodell (Fig. 14). The purpose of dila- 
tation is to make the endometrium accessible to certain therapeutic 
measures, either medicinal or instrumental. In a narrow, or pin-hole, 
os it becomes necessary to dilate the channel before using 
the curette or making applications to the endometrium. 
Where but little dilatation is required, occasionally the 
glove stretcher or metallic dilator can be used without an 
anaesthetic; but usually when it becomes necessary to em- 
ploy the more complicated instrument of Goodell, anaes- 
thesia to the surgical degree should precede its use. 
When the os is patulous, curettage for diagnostic purposes 
may be made sometimes without resorting to anaesthesia. 
Diagnostitial dilatation often becomes necessary for the 
purpose of admitting the finger into the uterine cavity. 
It is an operation, however, that should never be made 
when there is a sensitive uterus to contend with, or when 
the pelvic tissues have been invaded with inflammatory 
conditions; in other 'words, it is necessary to surround 
this operation with all the precautions that pertain to 
formidable procedures. It is not to be done in the con- 
sulting room and the patient allowed to make her way 
homeward afterward, but it should be done either in hos- 
pital or at home, in order that the patient may be kept 
entirely quiet for the next few days thereafter. This 
operation is to be preceded with the seizure of the an- 
terior lip of the cervix by the volsella, or strong tenac- 
ulum. The cervix is thus stretched and the dilator 
gradually and slowly passed into the cervical canal, the 
bougie with a rotary motion, the glove stretcher with a 
spreading of the blades in a gentle manner, just within 
the os, advancing a little farther and stretching again, 
and so on until the work is completed. 
The Curette as a Means of Exam- 
ination. — This instrument is used to ob- 
tain scrapings from the endometrium 
with a view to determine the nature of 
any disease that may not otherwise be ex- 
plained. These scrapings may be sub- 
mitted to examination by the microscope. If malignancy is ascer- 
tained, the further method of procedure is readily pointed out. If 
there are remains of an abortion, or an endometritis that has fol- 
lowed abortion, then the interior of the uterus should be thoroughly 
cleaned, mopped with pure carbolic acid or carbolic acid and iodine, 
and the organ should be packed with antiseptic gauze. The curette 
is often used unnecessarily, and great caution should be observed 




Fig. 14. — " The mechanical steel 
dilator of Goodell.' 1 — Potter. 



DIAGNOSIS 47 

in its employment. The puerperal womb is easily perforated, an 
accident that has often happened in unskilful hands. 

The Cystoscope as a Means of Diagnosis. — (See Examination of the 
Bladder.) 

The Aspirator as a Means of Examination. — This instrument is 
sometimes appealed to when cysts or pus pockets develop along the 
broad ligament. In doubtful cases these sacs may be explored through 
the roof of the vagina, but it is generally sufficient to diagnosticate 
them by the usual means, and to evacuate them by surgery through the 
abdomen or vagina. 

The stethoscope is occasionally employed to ascertain the nature of 
abdominal diseases, especially when pregnancy is suspected. The uter- 
ine dressing forceps and the depressor are an essential accompaniment 
to the armamentarium and need no particular description. The forceps 
carries cotton in wiping the tract, and the depressor holds the bladder 
away from the field during inspection. The tenaculum and volsella 
are used to seize the lips of the uterus in order to draw down the organ 
or to steady it while the parts are being inspected and applications 
are being made. These instruments should be dipped in pure carbolic 
acid before using. 

Examination of the Urinary Tract. — (See Examination of the Se- 
cretions and Diseases of the Urinary Tract.) With this, should be asso- 
ciated a systematic investigation of the various parts of the body. 
It is well enough for convenience 7 sake to begin with the upper 
air-passages; nose, throat, and fauces, should be investigated, par- 
ticularly in cases in which there exist head or nerve symptoms, so 
frequently referred to as genital reflexes. A similar investigation under 
similar circumstances should be made of the eyes and ears. Careful 
auscultation and percussion of the heart and lungs should be made 
when there are irregularities of the former, or when the latter may be 
subjected to suspicion by pelvic or other symptoms suggestive of 
tuberculosis. It is not presumed that every practitioner is capable 
of making a thorough examination of each of these several organs; 
but any one who assumes to practise gynecology should be so thor- 
oughly grounded in a general knowledge of medical science that he 
can. with reasonable accuracy, determine departures from health in 
all bodily structures or functions. If it is necessary to carry an 
examination of any of these organs to the point of technical perfection, 
they can be. and should be, relegated to special practitioners for that 
purpose. 

Intrapelvic disease is a fruitful cause of perversions of practically 
all of the secretions. These functional disturbances, in turn, become 
factors in the case and need to be dealt with as such. 

The Urines. — In consequence of the great advance which has been 
made in the study of pathologic conditions of the genito-urinary tract, 
and in view of the fact that the urine secreted by either kidney differs 
from that secreted by the other, it is now important to speak, not of 



48 A TEXT-BOOK OF GYNECOLOGY 

the urine, but of the urines, when reference is made to the secretions 
which accumulate in the bladder. The technique involved in securing 
the urine from either kidney is considered in the chapter devoted to 
that subject. The investigation of the blended urines, however, is still 
a matter of clinical importance. Care should be taken to determine 
their quantity, colour, and specific gravity, the presence or absence of 
albumin, glucose, mucus, tube casts, pus, or other morbid products. 
In view of the importance of xanthine and the paraxanthines in the 
causation of various nervous phenomena, an examination of the urine 
will frequently need to embrace a qualitative and quantitative deter- 
mination of these substances. Urea and uric acid are of clinical im- 
portance and need to be studied. In many cases it will be important, 
not only to study the urine from each kidney, but also to study each 
urine and the blended urines repeatedly. To insure completeness of 
examination it is important to follow the usual blanks available for 
the purpose. 

Faeces. — In many gynecologic cases, particularly in those associated 
with marked disturbances of nutrition, it is of great importance to 
investigate carefully the faeces. Their naked-eye characteristics should 
be noted, and microscopic studies should be made of various kinds of 
their constituents. Blood, fats, parasites, fungi, foreign bodies, mucin, 
ferments, hydatids, etc, are only mentioned to suggest the range of in- 
quiry which should be made in many of these cases. The reader is 
referred to Jaksch^s Clinical Diagnosis. 

The Menstrual Discharge. — It is often important to determine with 
accuracy the quality and quantity of the menstrual discharge. To 
determine its character the napkins should be preserved and inspected. 
It should be remembered, however, that the absorption of the blood by 
the napkin modifies to an important degree the colour of the former. If 
more critical examination needs to be made, some of the discharge can 
be mounted upon a slide and put under the microscope. If there is 
occasion to ascertain the quantity passed, the napkins should be care- 
fully weighed before and after being used. In some cases it is impor- 
tant to determine whether the discharge is a true menstrual flow or a 
lochial discharge. For this purpose the microscopic examination is 
essential. It may be mentioned in this connection that in the men- 
strual flow immediately after its onset, there occur abundant red blood- 
corpuscles and prismatic epithelial cells laden with fat. These are 
derived from the interior of the uterus. As soon as the physiologic 
climax of the flow has been reached, the red blood-cells diminish and 
the leucocytes progressively increase until the flow disappears. The 
fluid which passes following a parturition, is, in the absence of hemor- 
rhage, thinner in consistence, with less tendency to coagulate. While 
it abounds in red and white corpuscles from the start, it shows, also, 
abundant epithelium from both the uterus and vagina. Unlike men- 
strual fluid, the lochia, even in the absence of septicaemia, abound in 
microbes. 



DIAGNOSIS 



49 



The Blood. — Every practitioner should provide himself with the 
necessary instruments for the examination of the blood. These should 
include an apparatus for counting the blood-corpuscles, chromo-cytom- 
eter, and a hemometer. With these instruments and a good micro- 
scope, with which all modern practitioners are presumed to be pro- 
vided, it will be possible to determine the blood state of patients. 
This is an exceedingly important diagnostitial measure in gynecological 
practice. Thus a marked leucocytosis, taken in connection with other 
symptoms, is confirmatory of a suppuration which may be situated so 
remotely in the pelvis as to defy detection. 01igochroma?mia, in vary- 
ing degrees, may be accepted as an index of general states of nutrition; 
the perturbation of which may depend, in the first instance, upon ob- 
scure and otherwise undetectable conditions within the pelvis. Eeed 
has shown (American Journal of Obstetrics and Gynecology) that many 
perverted conditions of the blood are caused in the first instance by 
disease of the pelvic organs, the disturbing influence of which is exer- 
cised, through the intimate nerve connections, upon the hematogenetic 
function. When these changes and their causation are better under- 
stood, the diagnostic value of blood states, considered as indicative of 
intrapelvic disturbances, will be greatly enhanced. 

The Nervous System. — The intimate relation of the entire genital 
apparatus with the nervous system (see Xervous Complication^ in 
G}Tiecology) renders it important that the gynecologist should make a 
careful note of the actual state of the nerve functions. He should learn 
to appreciate nerve disturbances as much from the neurologic as from 
the gynecologic standpoint. Motor and sensory disturbances should be 
determined by "instruments of precision, while the special senses should 
be investigated with accuracy. Psychic states should be studied with 
care. Careful attention to these precautions will speedily result in 
reducing the now chaotic subject of " genital reflexes " to a somewhat 
scientific basis. 



CHAPTER YII 
SEPSIS 

Sepsis defined — The bacteria of sepsis — Local sepsis: Symptoms, pathology, and 
treatment — General sepsis : Symptoms, pathology, and treatment. 

Sepsis — derived from the Greek word <rr)if/Ls (from o-rjireo-Oai, to rot); 
French, sepsie; German, Fdulnis — is defined by Foster as putrefaction, 
rotting; in medicine, the morbid condition resulting from the absorp- 
tion of putrid or putrescent material or of germs capable of causing 
putrefaction. As used in this connection it implies a condition of 
either (a) local, or (b) general, infection by pathogenic micro-organisms. 
The relation of bacteria to fermentation and putrefaction was first 
demonstrated by Pasteur, from which phenomena he deduced the the- 
ory that suppuration in wounds was probably due to external agencies, 
and, by subsequent experiments, demonstrated the correctness of his 
analogy. The theory thus established found its first practical appli- 
cation at the hands of Lister, who, by a succession of careful and 
painstaking experiments and clinical observation, laid the foundation 
for the technique of antisepsis. The entire practice is based upon the 
now demonstrated and accepted fact that micro-organisms are the 
essential factors in the causation of both local and general sepsis. 
These micro-organisms embrace both micrococci and bacilli, a compre- 
hension of the identity and pathogenesis of each of which is essential 
to an understanding of sepsis, its prevention, and treatment. 

The Bacteria of Sepsis 

Micrococci. — Of the micrococci both the staphylococci and the 
streptococci play important parts, often coincidently, in producing 
sepsis. 

(A) Staphylococci, although occurring in several varieties, have a 
more or less common morphology in the particulars that they are (a) 
small, spherical cells; (b) that they vary from 0.7 /* to 0.9 /x in diam- 
eter; that they occur singly, in pairs (diplococci), frequently in fours 
(tetrads), or in masses (zoogloea). The varieties about to be considered 
differ from each other chiefly in colour, the character of the pigment 
they throw off, their behaviour in different media, their degrees 
of virulence, and finally in the particular of their natural habitat. 
While there are other varieties of staphylococci, but four will be con- 
sidered in this connection — viz.: (1) The Staphylococcus pyogenes aureus 
is the most common pathogenic micrococcus (Fig. 15). Having the 
50 



SEPSIS 



51 




morphologic feature already mentioned, it is only important to add that 
it multiplies rapidly at normal temperatures in nutrient media. While 
growing in gelatine, which these cocci liquefy, they accumulate near 
the surface, producing, when brought in contact with the air, a charac- 
teristic golden-yellow pigment which is precipitated to the bottom of 
the tube and from which they take their name. Sternberg gives the 
thermal death point in moist media at from 56° to 58° C. (132.8° to 
136.1° F.), but when dried at from 90° to 100° C. (194° to 213° F.) 
these germs grow in either the presence or absence of ox} r gen, and 
are capable of reproducing themselves when transplanted from nutrient 
media at the end of a year, and they have been found alive at the 
end of ten days after having been dried 
on a cover glass. Their natural habitat 
on the body is the cutaneous and mu- 
cous surfaces, although they have been 
found in the salivary secretions, in the 
dirt under the finger nails, and in the 
mucus from both the pharynx and nose; 
they have also been found in the soil, 
the air and water, upon the surface of 
fruits, and on the petals of the rose. The 
pus-forming quality of this coccus is be- 
yond doubt. Von Eiselberg and Netter 
have shown that it is transported by the 
blood to other parts of the system, but 
there is no conclusive evidence that it multiplies within that medium. 
(2) The Staphylococcus pyogenes alius is precisely like the preceding 
in morphology except that it is not pigmented. Surface cultures 
made from this coccus are milk white, from which fact it takes its 
name. According to Eosenbach, who discovered it, this albus occurs 
more commonly among the lower animals than does the aureus. Patho- 
logically it is often found alone in acute abscesses, but more frequently 
in company with other pyogenic bacteria. It is probably identical with 
the micro-organism next to be described. (3) The Staphylococcus epi- 
dermidis albus (Welch) has physical properties precisely like those of 
the preceding, but differs from the aureus in colour, in the fact that it 
liquefies gelatine more slowly, that it is less virulent when introduced 
into the tissues, and that it may be present in wounds without causing 
pus. This latter statement is made by Welch in face of the declaration 
that it has been demonstrated to be the frequent sole cause of suppura- 
tion along the drainage tube and in stitch abscesses. Its natural habitat 
is the skin, into the interstices of which it is frequently buried so 
deep as to be beyond the reach of the agents usually employed in hand 
sterilization. This was interestingly demonstrated by Dr. Thomas C. 
Craig, United States Navy (New York Medical Journal, April 11, 1896), 
who, in a search for malarial organisms in a fever patient, sterilized the 
palmar surface of the latter's finger, which he pricked deeply with a 



Fig. 15. — " The Staphylococcus 
pyogenes aureus is the most 
common pathogenic micro- 
coccus." — Eeed (page 50). 



52 



A TEXT-BOOK OF GYNECOLOGY 



needle previously sterilized in an alcohol flame. Three drops of the 
resulting blood were thrown away; the top of the next drop was touched 
with the point of a sterilized platinum wire and a stab culture in agar 
made. Three cultures were thus made, two of which proved negative, 
while the third yielded the Staphylococcus epidermidis albus of Welch. 
While this is an isolated observation it tends to show that, even upon a 
palmar surface, in the absence of sebaceous glands and hair follicles, 
this coccus may be situated so deeply as to elude careful antiseptic 
precautions. (4) The Staphylococcus pyogenes citreus, while having 
morphologic features in common with other micrococci, differs from 
them in the particulars that its coloured pigment is of a lemon yellow, 
that its pigment is formed only in presence of oxygen, that it is slowest 
of all of the micrococci in liquefying gelatine, and, finally, that al- 
though it is found with other bacteria in acute abscesses, its own 
pathogenesis is undetermined. 

(B) Streptococci, like the preceding organisms, have a common mor- 
phology depending upon the fact that, after the cocci have multiplied 
by binary division in a single direction, the resulting segments arrange 
themselves into chains (Fig. 16). The chains thus formed may be long 
or short, single or arranged into bundles. While there are numerous 
varieties of streptococci, it is necessary for this chapter to consider 
only the Streptococcus pyogenes, in which the cocci are spherical — from 
0.1 /a to 1 p in diameter — those in the same chain or in different 

chains varying in diameter. This strep- 
tococcus grows both in the presence and 
absence of oxygen and does not liquefy 
gelatine. Considered pathogenetically, it 
causes inflammation when injected into 
the tissues of lower animals, in some of 
which, notably in mice, with lowered vital- 
ity, it multiplies within the body and causes 
death. It is demonstrated to be the essen- 
tial causative factor in erysipelas, from 
which fact it is sometimes designated the 
Streptococcus erysipelatos. It is also recog- 
nised as the streptococcus of puerperal 
fever, a fact which explains the now uni- 
versally recognised causal relation of ery- 
sipelas to the latter. disease. Czerniewski 
found this coccus but once in the lochia of 57 healthy lying-in women, 
while he found it in the lochia of 35 out of 38 women with puerperal 
fever, and in 10 fatal cases it was present in the lochia before and in 
the organs after death. The inference from these observations has 
been abundantly confirmed, especially by Clivio, Widal, Eiselberg, 
Emerich, and Bumm. It also plays an important part in the inflam- 
mation of mucous membranes. 

The Micrococcus gonorrhoeae, familiarly known as the gonococcus of 



r 



..•<"H5 



*2 



^mM 



Fig. 16. — " After the cocci have 
multiplied by binary division 
in a single direction, the result- 
ing segments arrange them- 
selves into chains." — Reed. 



SEPSIS 



53 



Neisser (Fig. 17), is a micrococcus occurring in pairs or in groups of 
four, but generally in the form of diplococci. Its elements are flattened 
or " biscuit-shaped." " The flattened surfaces," says Sternberg, " face 
each other and are separated, in stained preparations, by an unstained 
interspace. The diameter of an associated pair of cells varies from 0.8 ft 
to 1.6 ft in the long diameter — average about 1.25 ft — and from 0.6 ft 
to 0.8 ft in the line of the interspace between the biscuit-shaped 
elements, which sometimes present a slight concavity of the flattened 
surfaces. Multiplication occurs alternately 
in two planes, and as a result of this, groups 
of four are frequently observed. But diplo- 
cocci are more numerous and are considered 
as the characteristic mode of grouping. 
Single, spherical, undivided cells are rarely 
seen." There are other micro-organisms 
with a morphology identical with the gono- 
coccus, which, therefore, must depend for its 
distinction upon other features. Among 
other facts to be taken into consideration in 



1% £ II 




%ef 


M £ 







this connection are its response to staining 



Fig. 17. — il Familiarly known as 
the gonococcus of Neisser." — 
Keed. 



agents; the fact that it is aerobic; that it is 
a strict parasite; that in culture media it 

is self-limiting in its vitality; that it will not develop below 25° C. 
(77° F.) or above 38° C. (100.4° F.); that, exposed to 60° C. (140° F.) 
for ten minutes, it dies; and, finally, it is distinguished by the clinical 
phenomena attending its occurrence. Studied pathogenetically, it has 
been demonstrated to cause the form of inflammation known as gonor- 
rhoea, upon the mucous membrane of the urethra, the cervix uteri, the 
corpus uteri, and the vagina of children; while the vaginal mucous 
membrane of adults appears to be immune. The conjunctiva is also 
capable of inoculation — a fact which accounts for the frequent occur- 
rence of ophthalmia neonatorum. Bockhart has found that the gono- 
cocci penetrate into the deeper layers of the urethral mucous mem- 
brane, even into the corpus cavernosum, although Bumm is of the 
opinion that, as a rule, the epithelial layer of the mucous membrane is 
alone involved. In its later stages gonorrhoea often becomes a mixed 
infection, owing to the presence of the Staphylococcus pyogenes aureus, 
upon which, rather than upon the gonococcus, all metastatic manifesta- 
tions depend. 

Bacilli. — The pathogenic bacilli, like the micrococci, have a com- 
mon morpholog}^, in the particulars that they are spheroidal, rod- 
shaped, or spiral in form (Fig. 18). The ends of the rods may differ, 
some being square, others oval, etc., the difference existing between 
the ends of different rods rather than of the same rods. Of the 
several hundred known bacilli it is necessary in this connection to con- 
sider but three — viz.: (a) Bacillus coli communis, (b) Bacillus aerogenes 
capsulatus, and (c) the Bacillus tuberculosis. 



54 



A TEXT-BOOK OF GYNECOLOGY 



(a) The Bacillus coli communis, morphologically, consists of short 
rods with rounded ends, generally occurring in pairs (Fig. 19), about 2 /jl 
long and from 0.4 /a to 0.6 /x broad. In some instances the diameter and 
the length are equal, under which circumstances they may be mistaken 
for micrococci. They propagate both with and without oxygen, and 
are both parasitic and saprophytic. They are capable of slight amoeboid 
activity. They propagate actively in acid media of abnormal tempera- 




Fig. 18. — "Bacilli are spheroidal, rod-shaped, 
or spiral in form." — Reed (page 53). 




Fig. 19. — " The Bacillus coli communis. 
— Reed. 



ture. There are several varieties of this bacillus, all of them possessing 
a common morphology though differing slightly in habitat, behaviour 
in similar media, and in degrees of virulence, but it is not necessary in 
this connection to speak of them in detail. In the normal body the 
habitat of the Bacillus coli communis is in the colon and adjacent por- 
tions of the alimentary canal. Its migration from this locus, through 
an infection atrium, into either the walls of the intestines or the peri- 
toneal cavity is fraught with serious mischief. (See Bacteriology of 





Fig. 20. — " The Bacillus aerogenes capsu- 
lars (Welch-Nuttall.)"— Reed. 



Fig. 



21. — a The Bacillus tuberculosis 
(Koch.)" — Reed (page 55). 



Appendicitis.) It has been found in common with other micro-organ- 
isms in puerperal fever. 

(b) The Bacillus aerogenes capsulatus (Welch-Nuttall, Fig. 20) oc- 
curs, ordinarily, as a straight but sometimes slightly curved bacillus, 
with ends that may be square or slightly rounded, and from 3 to 6 /a in 



SEPSIS 55 

length. It has a transparent capsule; is without the power of spon- 
taneous movement; is sporeless; thrives without oxygen at normal tem- 
perature; and generates gas in large quantities in all culture mediums. 
Animals inoculated with this bacillus speedily die, the bacillus propa- 
gating rapidly and developing gas in the dead tissues. It is the bacillus 
most probably responsible for the gas which occasionally occurs in 
tissues in connection with suppuration. 

(c) The Bacillus tuberculosis (Koch, Fig. 21) consists of rods from 
1.5 {jl to 3.5 [jl long and from 0.2 fi to 0.25 fx broad. They are gener- 
ally slightly curved, but sometimes angulated, and in stained specimens 
exhibit unstained intervals. They are usually single, but are occasion- 
ally double. They are peculiar in that they do not readily take up ani- 
line colours, and that when once stained they clo not decolourize with 
facility, even by strong acids. They are parasites, but under ordinary 
circumstances they are not saprophytic. They grow only at a tempera- 
ture of about 37° C. (98.6° F.), and that the}^ develop spores in the pro- 
cess of growth is not established. Koch affirms that they are killed by 
exposure to the direct rays of light, although Sawizky states that tuber- 
culous sputum, under the conditions of ordinary habitation, may retain 
infectious power for as long as ten weeks. A fact of practical impor- 
tance is that they develop a toxine which produces febrile reaction. 
Pathogenetically, it is sufficient for the present purpose to say that, 
introduced into the system, this bacillus causes tuberculosis both in the 
lower animals and man. 

Varieties of Sepsis. — For the purposes of this work sepsis is divided 
into local and general. 

Local sepsis implies the infection of a circumscribed area of tissue 
with pathogenic bacteria. Such infection results generally, but not 
always, in suppuration, which may be either superficial, as in ulcera- 
tion, or interstitial, as in the formation of an abscess. Suppuration 
consists in the conversion of normal tissue elements into a fluid called 
pus. Pus is of variable consistence, of high specific gravity, of alkaline 
reaction, and of a colour varying from grayish to greenish yellow. 
Anjr variation from yellow depends upon the presence in the pus of 
added elements. Microscopically, pus is found to contain leucocytes, 
some of which are normal in size and contour, others are dead and 
shrunken, while still others are very large and polynuclear, and are 
known as giant or pus corpuscles. There are some red blood-corpus- 
cles, frequent fat-laden cells, and some epithelial elements. Passet 
cultivated from pus eight different kinds of fungi, chief among which 
were the staphylococci, streptococci, and bacilli of various sorts; among 
the last, in different cases, were observed the bacillus of tuberculosis, 
the bacilli of glanders, of leprosy, and actinomyces. Filiaria and 
infusoria are also occasionally found. The crystalline elements of pus 
are cholesterin, hematoidin, the crystals of fatty acids, and the triple 
phosphates. 

The treatment of sepsis divides itself naturally into preventive and 



56 A TEXT-BOOK OF GYNECOLOGY 

curative. Under the first head are embraced all those measures 
which are calculated to destroy the pathogenic bacteria existing 
upon the integument or upon dressings, instruments, ligatures, or 
sutures, and which may thence and thereby be brought in contact 
with such tissues as may be exposed in the course of a surgical oper- 
ation. They are designed to produce a condition known as asepsis. 
This word deserves a little consideration; its definition, as given by 
Foster, is as follows: 

Asepsis — from a privative and o-^ts, putrefaction; French, asepsie; 
German, Asepsie — means freedom from putrid or putrescent material 
and from septic germs. 

It has come to be used, in surgical nomenclature, to imply an ex- 
alted state of ordinary cleanliness, to secure which it is not necessary to 
employ the usual germicidal measures and agencies. In many quarters 
it is accepted as true that asepsis is a very natural condition. This view 
is misleading and dangerous. The very contrary, indeed, may be as- 
serted — namely, that the condition of absolute asepsis, particularly as 
relates to the human integument, not only does not exist naturally, 
but is almost impossible of attainment. This being true, the word 
" asepsis " should be used only to imply such a state of freedom 
from septic elements as can be attained by the use of antiseptic 
measures and agencies. As a matter of fact, all the measures and 
precautions usually designated under that head are directed against 
septic micro-organisms and are consequently measures of anti- 
sepsis. This word — from <Wi, opposed to, and o-r)\J/i<i, putrefaction 
(French, antisepsie; German, F dulnisliemmung) — means any procedure 
or combination of procedures for preventing, limiting, or stopping, 
putrefaction or for destroying putrefactive germs. 

The attempted limitation of the meaning of " antisepsis " to the 
treatment of conditions of obvious infection is not warranted by its 
etymology or by its recognised scientific application. Those antiseptic 
measures which are adopted as preliminary safeguards to an operation 
may properly be grouped under the title of the preventive treatment 
of sepsis. (See Antisepsis.) 

Symptoms of Local Sepsis. — When local infection occurs, it causes 
a circumscribed inflammation, characterized by the cardinal signs of 
heat, pain, redness, and swelling. In the course of a few days, if the 
infection has not been mastered by the action of the leucocytes, pus 
forms; the micro-organisms upon which it depends for its elaboration, 
having penetrated into the normal tissues, continue to propagate, re- 
sulting in the progressive formation of pus. This is observable in areas 
of infection upon the surface, as well as in the gradually increasing 
volume of an abscess. 

Treatment of Local Sepsis. — The fact that pyogenic bacteria are 
inhibited at low temperatures is of practical importance in the treat- 
ment of the earlier stages of local infection. Cold, applied persistently 
over the seat of infection not too deep to be influenced by it, may 



SEPSIS 57 

arrest the propagation of the bacteria until the leucocytes have had 
time to subdue the advance guard of invasion. Cold is, therefore, a 
remedy of great value in the early treatment of these cases, when for 
any reason it is not deemed best to open the wound and treat it by 
direct antisepsis. This is the course of election in the majority of 
cases. The focus of infection should be freely incised and washed 
out, first, with sterilized alkaline water, next with hydrogen peroxide, 
and subsequently with the bichloride solution. The wound should 
then be packed with bichloride gauze and changed daily. If the wound 
still manifests a tendency to suppurate, the fact indicates that the bac- 
teria have penetrated too deeply to be influenced by the antiseptic 
agents. It is better, under such circumstances, to freely curette the 
wound down to the normal and unaffected tissues, then to wash it out 
with the peroxide, and treat it as before. Active escharotics, such as 
the nitrate of silver, may be used to cauterize the wound, and thus to 
remove the infected tissues. 

General sepsis, as used in this chapter, means the intoxication of 
the system with some poisonous agency of bacterial origin, and includes 
the clinical conditions designated by toxaemia, septicemia, saprcemia, 
pycemia, etc. The state of general sepsis presupposes a point of local 
infection, although the local infection may not result in suppuration. 
There are many cases of general sepsis in which the constitutional 
symptoms develop and run to a fatal issue before the local infection, 
upon which they depend, has had time to develop suppuration. That 
constitutional sepsis depends primarily upon local bacterial invasion 
is established by (a) the frequency with which it follows known local 
infection, (b) the extreme rarity of its occurrence in the absence of 
some demonstrable nidus of infection, and (c) the demonstrated exist- 
ence in the blood of bacteria which of necessity must have had an 
extra corporeal origin. Von Eiselberg has demonstrated both staphylo- 
cocci and streptococci in the blood of septic patients. While the role 
that these bacteria play in the circulation can not be doubted, it has, 
nevertheless, been proved by Eosenbach that actual bacterial invasion 
of the circulation is not essential to the causation of constitutional 
sepsis; he concludes, on the contrary, that septic symptoms are due 
rather to the absorption of poisonous ferments and ptomaines. 
These, having their origin in a local infection, are given off 
and multiply more rapidly than do the micro-organisms them- 
selves. It is this latter fact which explains the celerity with 
which septic symptoms develop after a local infection has occurred in 
cases in which bacteria can not be demonstrated in the blood. In cer- 
tain cases, however, bacteria are present in large numbers, a few of them 
succumbing to the action of the leucocytes, while others are deposited 
in the terminal capillaries, where they become foci of secondary sup- 
puration. Eeed has recorded a case in which one hundred and twenty- 
four secondary, or metastatic, abscesses occurred, in which the patient 
finallv recovered. 



58 A TEXT-BOOK OF GYNECOLOGY 

Symptoms of General Sepsis. — In considering the symptomatology 
of septic constitutional states it may be well to distinguish between 
those clinical entities designated as septicaemia and pyaemia. In septi- 
caemia the fever curve, which may begin without an initial chill, grad- 
ually rises almost without vacillation until it is arrested within the 
thermic range of life, or else until it passes that point and death ensues. 
Those cases in which the system has sustained injury, such as stran- 
gulated hernia or gunshot wounds of the abdomen, and, where death is 
said to be due to septicaemia, in which the temperature has been under 
rather than above the normal line, are to be classed as cases of shock 
rather than of septicaemia. Prostration, headache, anorexia, with lassi- 
tude and stupor, supervene. Diarrhoea is common; lymphatic engorge- 
ment is generally detectable; the skin is pale and sometimes reveals a 
slight scarlet eruption. The skin in the earlier stages is parched, but 
later the perspiration becomes active, with increasing sallowness of 
complexion, increasing listlessness, increasing weakness and rapidity 
of the pulse, and diminished urinary secretion; from the initial chill, 
through the whole course of the disease, the pulse shows increased 
frequency with diminished force, until it disappears at the wrist; de- 
lirium obtunds the consciousness until coma merges the patient into 
death. In pyaemia the symptoms do not set in so speedily after opera- 
tion, generally not until the second week. They begin with a chill fol- 
lowed by sudden rise in the temperature line. The subsequent course 
of the disease is characterized by a repetition of the chills, followed in 
each instance by a rise of temperature. The periodicity between these 
exacerbations is characterized by marked irregularity. The fall, how- 
ever, rarely if ever reaches the normal line. About this time meta- 
static abscesses manifest themselves. These may occur in the subcu- 
taneous connective tissue in some superficial lymphatic in the neck 
or groin; purulent effusions into the pleura or into the joints may 
occur. The parotid and other glands are liable to infection. The mind, 
however, generally remains clear, and in those patients who go to a 
fatal termination, death seems to supervene upon progressive ex- 
haustion which finds its climax in arrest of the cardiac function. 

Treatment of General Sepsis. — In the management of general sep- 
sis the treatment is essentially antiseptic. (For preventive treatment 
see Antisepsis.) In septicaemia immediately following abdominal sec- 
tion but little good can be accomplished by reopening the abdo- 
men, although cases have improved following this treatment. When 
the abdomen is reopened, in those cases in which a discriminating 
judgment prompts the operation the peritoneum should be thoroughly 
washed with a normal saline solution and a drainage tube should be in- 
serted. The constitutional state should be combated by supportives. 
The early occurrence of vomiting, however, and its persistence will 
generally interfere with the administration either of remedies or nutri- 
tion by way of the stomach. Rectal alimentation should, therefore, be 
resorted to; when the stomach will permit of their exhibition, copious 



SEPSIS 59 

quantities of stimulants should be given. Heart stimulants, such as 
strychnine, digitalis, and, in later stages, nitroglycerine, are of value. 
Normal salt solution, given either by hypodermoclysis or by intraven- 
ous injection, has been observed to furnish a needed volume to the 
circulation and to re-enforce the patient's strength. The various anti- 
toxic serums have not yet yielded the benefit that it was hoped would be 
derived from their emplojmient, the theoretic explanation of the diffi- 
culty being that, whereas the serum was derived from the cultures of 
individual varieties of bacteria, infections are generally of the mixed 
variety, in the presence of which the special serum is relatively 
powerless. 



CHAPTER VIII 
ANTISEPSIS 

Antiseptic provisions of Nature — Sterilization: (a) Mechanical means, (6) heat, (c) 
germicidal agents — The nurse — The room — The patient — Instruments and 
dressings — Sutures and ligatures — Post-operative antisepsis — The surgeon: 
Hand sterilization; gloves. 

Antiseptic Provisions of Nature. — The word antisepsis, as previous- 
ly defined, implies any provision or procedure for limiting or stopping 
putrefaction or for destroying putrefactive germs. Nature herself has 
provided a double protection against invasion by pathogenic micro- 
organisms. The first of these provisions is expressed in what has come 
to be recognised as the law of Wyssakovitsch — viz.: that the epithelial 
cells covering any part of the body, while they maintain their integrity, 
protect the underlying structures and the general system against bac- 
terial invasion. The second of Nature's effective provisions is expressed 
in the law of Metschnikoff — viz.: that in the presence of bacterial in- 
vasion the leucocytes, both uninuclear and multinuclear, acting as 
phagocytes, attack and destroy the invading micro-organisms. All 
bacterial invasions of the body, therefore, can be said to take place 
only in the presence of an infection atrium, which implies the destruc- 
tion of a greater or less area of protective epithelium; and systemic 
contamination can not result until the invading bacteria, like a numer- 
ous army, has assailed and overcome the defending leucocytes. When, 
however, it is deliberately intended to make an infection atrium in the 
form of a surgical incision, and when it is contemplated thereby to 
establish circumstances so favourable to infection that the defending 
leucocytes must necessarily be overpowered, it becomes imperative to 
practise those safeguards which are conventionally designated by the 
word antisepsis. They embrace various methods of destroying micro- 
organisms which are known to exist upon the hands of the surgeon 
or his assistants and upon or within the integument of the patient; that 
cling to instruments; that infest materials utilized for sponges and 
dressings; or that exist in great abundance in the clothing and imme- 
diate surroundings of the patient. 

Sterilization, by which is implied destruction of micro-organisms 
in a given area or substance, is effected by (a) mechanical means, (&) 
heat, generally combined with pressure, and (c) chemical agents. 
60 



ANTISEPSIS 61 

Mechanical sterilization is practised by careful and prolonged Trash- 
ing with a detergent, and by heavy friction. Soap is the best detergent, 
but care should be taken that it is not itself contaminated. Frequent 
researches have shown that soap may be thoroughly infested with bac- 
teria. The danger from this source can be overcome by taking either 
the ordinary lye soap of the kitchen or the laundry, or, preferably, a 
known variety of pure soap, such as the ivory, diluting it with water, 
and boiling it for twenty minutes. This insures resterilization, 
should the soap have previously become contaminated. Brushes made 
of vegetable fibre are the best. (See Sterilization of the Hands.) Gauze 
material, purchased for use as sponges or dressing, particularly cheese 
cloth as obtained in the stores, contains starch; it should, there- 
fore, be washed carefully with soap as above prepared, and after being 
rinsed through sterilized water should be dried. This can be done either 
before or after the material has been made into the individual sponges 
or dressings, but in either event they must be subjected to resterilization 
before being used. (See Sterilization of Instruments and Dressings.) 
Filters, such as the Pasteur-Chamberlain, are of doubtful efficacy in 
separating micro-organisms from the water that passes through them. 

Sterilization by Heat. — Heat is utilized for the purpose of steriliza- 
tion in the form of both dry heat and moist heat and in the form of 
heat combined with pressure. Heat by itself, whether dry or moist, 
is sufficient if applied in high enough degree, to destroy bacteria, but 
it is not practicable at the same time to destroy the spores frequently 
given off by the micro-organisms. To destroy the spores at the same 
time that the bacteria are killed, it is generally necessary to employ 
heat under pressure. The germicidal property of heat depends upon 
the fact that all micro-organisms have a thermal death point varying 
from 52° C. (125.6° F.) to 64° C. (14T.2° F.). It is not necessary in this 
connection to study the powers of resistance to heat possessed by dif- 
ferent bacteria; but it is sufficient for practical purposes to rely upon 
the fact that exposure to a boiling temperature for ten minutes " will 
infallibly destroy all micro-organisms in the absence of spores when 
they are in a moist condition or moist heat is used.' 7 (Sternberg.) 
Spores, however, have greater powers of resistance, and some of them 
are not destroyed even after exposure for several hours to a boiling 
temperature. To destroy these reproductive bodies recourse is had 
either to interrupted sterilization — i. e., resterilization after twenty- 
four hours — or to a single sterilization under pressure. The latter 
method is generally employed in America, and consists in introducing 
the objects to be sterilized into a steam chamber into which steam is 
projected until a pressure of at least forty pounds is reached. The 
sterilizer devised by Col. John Fehrenbatch (Fig. 22) and used in the 
Cincinnati Hospital, consists essentially of a cylinder surrounding a 
sterilizing chamber, the double wall of which incloses a space (H, H, 
Figs. 23 and 24) half an inch across. Steam is forced into this hol- 
low space at a pressure of fifty pounds per square inch — ten pounds 



62 



A TEXT-BOOK OF GYNECOLOGY 



greater than that used in the sterilizing chamber — which keeps the 
walls at a temperature from six to ten degrees higher than that inside. 
This prevents a condensation of steam by the walls and, together 

with an arrangement by 
which the steam is pre- 
vented from coming into 
contact with the dress- 
ings until it has trav- 
ersed the whole space 
between the two cylin- 
ders, makes it unneces- 
sary to dry the dress- 
ings before use. 

The wire receiving 
basket is supported by 
flanges (K, K, Fig. 24), 
which keep it away from 
the walls of the cham- 
ber, allowing the steam 
to penetrate freely from 
all sides, and it has been 
found that the tempera- 
ture at the centre of a 
tightly wound package 
twelve inches in diame- 
ter is the same as that 
on the outside of the 
package. 

Any desired pressure, 
up to one hundred 
pounds, can be main- 
tained by an invisible, automatic arrangement while the steam is kept 
in constant circulation at the same time. The mechanism for closing 
the head makes it possible to secure a steam-tight joint in three sec- 
onds, the whole process of thorough sterilization consuming about 
fifteen minutes. 

All dressings, sponges, operation gowns, etc., should be sterilized, 
when practicable, by this means, while instruments should be boiled 
for ten minutes in water containing two drachms of powdered car- 
bonate of sodium to a quart of water. This solution has the double 
advantage of dissolving the capsule, which acts as a protective to some 
germs, and of keeping the instruments from rusting. (See Steriliza- 
tion of Dressings and Instruments.) Dry heat, involving, as it does, 
the desiccation of the micro-organisms, must be carried to a higher 
degree than is the case with moist heat. The temperature of 140° C. 
(284° F.), maintained for three hours, is required to destroy the spores 
of bacteria. 




Fig. 



22. — a The sterilizer devised by Col. John Fehren- 
batch." — Reed (page 61). 



ANTISEPSIS 



63 



Sterilization by Germicidal Agents. — Various salts, essential oils, and 
gases, have the property of destroying bacteria. The germicidal prop- 
erty of these different agents presents the widest range of variation. 

Those of the greatest value, mentioned in 
the order of their germicidal power, are 
mercuric iodide, silver iodide, hydrogen per- 
oxide, mercuric chloride, silver nitrate, chlo- 
carbolic acid, potas- 




rine, iodine, bromine, 
sium permanganate. 




Fig. 23. — "The sterilizer de- 
vised by Col. John Fehren- 
batch . . . consists essential- 
ly of a cylinder surrounding 
a sterilizing chamber, tbe 
double wall of which in- 
closes a space half an inch 
across." — Eeed (page 61). 



Fig. 24. — " The wire receiv- 
ing basket is supported 
by flanges which keep 
it away from the walls 
of the chamber, allowing 
the steam to penetrate 
freely from all sides." — 
Eeed (page 61). 



Some agents that 
have the highest ger- 
micidal power are of 
no practical value in 
surgery, because they 
destroy the tissues 
with which they are 
brought into contact. 
For practical pur- 
poses lysol or car- 
bolic acid in a two- 
per-cent solution, or 
the mercuric chloride 
(1 to 2,000), is all 
that is required. 
Peroxide of hydrogen is of value in removing possible infection from 
exposed tissue areas. Among the various detergent agents it is de- 
sirable to select those which have germicidal properties, such as tur- 
pentine, the oil of cedar, or alcohol. For dressings, boric acid, iodo- 
form, and aristol, have a demonstrated value; although in aseptic 
wounds with accurate coaptation of the margins, antiseptic agents are 
not generally required, the protective influence of the leucocytes and 
of the carefully adjusted sterilized dressing subserving all purposes 
against infection. 

The Nurse. — Those measures which are devised and practised for 
the prevention of sepsis, and which contemplate the sterilization of the 
hands of the surgeon and attendants and of the field of operation, of 
sponges, dressings, and instruments, as well as of the patient's imme- 
diate environment, involve the exercise of so much special knowledge 
and skill that they must be intrusted to a person of special training. 
In recognition of this fact, the leading hospitals of the world have 
been engaged during the past fifteen years in giving special courses 
of instruction and training to that class of women who have come to 
be known as graduate nurses. The services of the trained, or more 
properly the graduate nurse, are essential to the successful practise of 
aseptic surgery. She should be the possessor of bodily vigour, prefer- 
ably comely, of pleasant address, with an interest in her work, prompted 
both by a love of humanity and jmde in her profession. Such a person 



64 A TEXT-BOOK OF GYNECOLOGY 

in these latter days is thoroughly familiar with sepsis, its cause and pre- 
vention, as well as with surgical technique. With a mere statement of 
the operation intended, she may be left without further instruction 
to the preparation of the case and its surroundings. The nurse should 
always be equipped with not less than three uniforms, a number of 
aprons, catheters, rectal tubes, syringes, thermometer, and hypodermic 
syringe, the last named being the one article which can best be spared 
from her armamentarium. She should always have a plentiful supply of 
antiseptic tablets. She should also provide herself with record blanks 
and should keep a careful record of every essential fact relating to the 
preparation or the progress of the case. 

The Room. — It is always more desirable to operate in a well-con- 
ducted hospital, although any residence is a safer place for surgical 
work than is a poor hospital. In hospitals the operating room may be 
said to be the distinguishing feature. It is an apartment set aside 
exclusively for operations, and is constructed of impervious and thor- 
oughly washable walls, floors, and ceilings. It is arranged with refer- 
ence to satisfactory light, proper drainage, and the maintenance of a 
high and equable temperature. It is furnished with only sterilizable 
furniture and fixtures, consisting of glass-topped enameled tables upon 
which to place the patient, the instruments, sponges, etc. Incandescent 
lights are so arranged that the field of operation can be illuminated by 
that means, if required by circumstances of emergency. The opera- 
ting room is sometimes constructed to contain the sterilizing apparatus, 
but this is better done in an adjoining apartment, specially furnished 
and otherwise adapted for the purpose. It is desirable also to prepare 
the patient in an apartment adjacent to the operating room and con- 
taining special appliances for the purpose. In private residences an 
effort should be made to reproduce as nearly as possible the more ideal 
conditions of the hospital. The circumstances of the ordinary home, 
however, are all adverse to this realization, and enjoin upon the nurse 
the most serious responsibility in overcoming them. She should begin 
by having all furniture, including pictures and hangings, taken from 
the room; the walls, floors, and ceilings, should then be carefully wiped 
with a moist bichloride cloth, after which the floors, windows, and 
especially the doors and door knobs, should be scrubbed with a 1-to- 
2,000 bichloride solution. Each article of furniture that is thereafter 
brought into the room should be cleaned as thoroughly as possible 
before it is returned, and again gone over with a bichloride cloth after 
being brought in. The most important article of furniture to be con- 
sidered in this connection is the operating table. In the absence of a 
special table, one answering the purpose very well can be extemporized 
by utilizing an extension table such as is found in practically every 
dining room. This should be thoroughly scrubbed before it is brought 
to the operating room, and it should be set up by extending it a dis- 
tance of about 2^ feet, and by taking two of the boards, or leaves, ordi- 
narily used in the table, and placing them lengthwise upon the top, 



ANTISEPSIS 



65 



their ends resting upon the now extended ends of the table. A blanket, 
folded lengthwise, can now be placed over these boards, but ex- 
tending the whole length of the table. Above this should be placed 
some protective material, such as oilcloth rubber sheeting, or, in the 
absence of anything better, a number of newspapers, and over all a 
sterilized sheet. Sterilized towels may be placed over the corners of 
the table between which, upon opposite sides, will stand the surgeon and 
his assistant. This arrangement makes a really convenient operating 
table, and one that is not too broad. Another kind of table, easily ex- 
temporized by a carpenter or a handy man about the place, consists of 
two trestles, 32 inches high and about 18 inches wide. On these is 
placed a board from 12 to 18 inches in width; on this board is placed 
another and shorter one, bevelled at one end and surrounded at the 
other by a piece of iron fastened midway in the edge upon either side by 
screws. The bevelled edge of this board, resting against two screws set 
in the lower board, and elevated at the other end, will be supported by 
this iron brace, resting against some screwheads, thus making a very de- 
sirable and convenient Trendelenburg attachment (Fig. 25). Smaller 




Fig. 25.— " A very desirable and convenient Trendelenburg attachment." — Eeed. 



tables or stands should be provided for bowls, instruments, etc. At 
least four wash bowls should be provided and a dozen or more towels. 
Two pitchers, one containing hot and the other cold sterilized water, 
and two larger receptacles for a reserve supply of hot and cold water, 
should be provided. One wash bowl should be used for the preliminary 
6 



66 A TEXT-BOOK OF GYNECOLOGY 

ablution of the hands, the other should contain some alcohol, and a 
third the bichloride solution. The room should be maintained at a 
temperature of about 85° F. 

The Patient. — The patient having been given the preliminary laxa- 
tive and general bath described more in detail in the chapter on Ab- 
dominal Section, is divested of her clothing and is placed between ster- 
ilized sheets. If she is able to take a general bath in a tub as an inter- 
mediate step, so much the better; but if she is not able to do this she 
should be given a general sponge bath, care being taken to avoid chill- 
ing her. After the general bath the pubes and pudendum should be 
shaved. They are then rinsed thoroughly with soap and water. The 
patient is next given a careful vaginal douche consisting first of clear 
water; while this douche is in progress the nurse should insert into 
the vagina some soap, and with her finger thoroughly wash the vaginal 
walls up to the uterine juncture. After a half gallon of plain hot water 
has been used in the douche the vagina should be irrigated with a hot 
bichloride solution (1 to 2,000). The abdomen should then be exposed 
and thoroughly soaped. The skin should be vigorously scrubbed for 
ten minutes with a brush. This is a manipulation the proper per- 
formance of which requires judgment on the part of the nurse. A 
nurse who does not understand her business will simply follow direc- 
tions to the letter and will scrub the skin with a rough brush for ten 
minutes regardless of consequences. It is important to remember 
that undue pressure is unnecessary for the proper cleansing of the 
skin, and is liable to do damage to the internal inflamed organs; 
while pressure which is too vigorous will rub off patches of epithelium. 
This should be carefully avoided, as every area of abrasion may be- 
come an infection atrium. After thoroughly washing the abdominal 
wall, any remaining fatty material should ,be removed by the use of 
either ether or alcohol. The alcohol should be clean and fresh. The 
solution of mercuric bichloride (1 to 2,000) should then be applied, 
first in the form of an ablution, and finally in the form of a pack, 
consisting of a towel saturated with the bichloride solution, cov- 
ered with other towels, and kept in position by a retaining bandage. In 
cases of operation upon the perineum or the vagina practically the same 
precautions should be taken with regard to the pudendal integument. 
The final moist dressings, comprising the last step in the process of 
sterilization, should be kept in position until the patient is placed upon 
the operating table. The nurse with her own hands, previously re- 
sterilized, then removes the preparatory dressings, and again washes 
the abdomen with alcohol, followed by the bichloride solution. All 
of the bichloride solution thus used should be carefully absorbed by 
sterilized sponges; otherwise, by remaining upon the surface of the 
abdomen, it is brought in contact with the surgeon's blade to the almost 
instant ruin of its edge. 

Instruments and Dressings. — Sponges are but rarely used in abdom- 
inal and pelvic surgery, the preference being given to small pieces of 



ANTISEPSIS 67 

gauze, which after being used to absorb blood or discharges are instant- 
ly thrown away. There is no doubt that this change has marked a 
distinct advance in aseptic surgery. Dressings are made of the same 
material. In hospitals both sponges and dressings of gauze are made 
in large quantities and are sterilized by washing (see Mechanical Ster- 
ilization) and by being subjected to heat under pressure in a steam 
sterilizer. In private practice it is better to secure a bundle of sponges 
and dressings that have been thus sterilized, but when this is not prac- 
ticable, it is better, after washing, boiling, and drying the material, to 
make it up into sponges and dressings, which are then to be resterilized 
in a bundle by putting them into the oven of the kitchen stove, where 
they are permitted to bake until the outer covering is thoroughly 
scorched, the heat having been maintained for not less than half 
an hour. 

Sutures and Ligatures. — Sutures are used to approximate margins 
of a wound, and consist usually of silk, catgut, silkworm gut, silver 
wire, or iron wire. These materials are all now susceptible of being- 
sterilized by heat, with the exception of catgut; simple boiling in plain 
water will answer the purpose. Ligatures are used for hemostatic pur- 
poses and consist of silk and catgut. 

Catgut, as known to commerce, is prepared from the intestine of 
the sheep, and its use in surgery has been designated by Xussbaum as 
Lister's greatest discovery. It has the advantages of being strong, 
flexible enough to be tied into a safe knot, capable of complete steril- 
ization, and completely absorbable when left either within the perito- 
neal cavity or the parietal structures. Since the secret of its steriliza- 
tion has been discovered, it possesses no disadvantages that are worthy 
of consideration. It was formerly looked upon as a fertile culture medi- 
um when left in tissues that were previously the seat of infection; it 
was justly recognised as being difficult of sterilization; and it was urged 
against it that it was liable to become absorbed too soon. With Hof- 
meister's formula, however, all these objections are at an end. This 
formula, which has been popularized in America through the influence 
of Nicholas Senn (Medical Mirror, January, 1897), is given by him as 
follows: " (1) The catgut is wound on a glass plate with slightly pro- 
jecting edges, so that the gut is free from the sides of the plate and ex- 
posed to the circulation of the boiling and flowing water. The ends of 
the gut are fastened through holes in the plate. (2) Immersion twelve 
to forty-eight hours in aqueous solution of formalin, two to four per 
cent. (3) Immersion in flowing water at least twelve hours, to free the 
gut from the formalin, (i) Boiling in water from ten to thirty minutes. 
Ten to twelve minutes is amply sufficient, as all microbes and spores are 
killed by exposure to boiling heat for that length of time. (5) Harden- 
ing and preservation in absolute alcohol containing five per cent of 
glycerine and one tenth of one per cent of corrosive sublimate." Senn 
modifies the above formula by boiling the deformalinized catgut from 
twelve to fifteen minutes, after which it is cut into pieces of desirable 



68 A TEXT-BOOK OP GYNECOLOGY 

length, and tied into small bundles containing from 6 to 12 threads, 
which are immersed and kept ready for rise in the following mixture: 
Absolute alcohol, 950; glycerine, 50; finely pulverized iodoform, 100. 
The alcohol dissolves part of the iodoform, which is presumed to add to 
the antiseptic value of the solution. Senn states that iodoform applied 
to recent wounds diminishes the amount of primary wound secretion. 
This, however, is contrary to the experience of Eeed, who has found 
less wound secretion from catgut prepared according to Hofmeister's 
formula, but preserved in Senn's fluid with iodoform left out. The 
absolute alcohol of itself is a safe precaution against the infection of 
the catgut. Goldspohn has had satisfactory results from catgut which, 
after being prepared by the Hofmeister formula and deformalinized in 
running water for forty-eight hours, was boiled for twenty minutes in a 
l-to-1,000 solution of pyoctanin in water, the excess of pyoctanin being 
washed out and the catgut preserved in plain alcohol. The tendon from 
the kangaroo's tail has been introduced into America, while those 
derived from the legs of the reindeer (ostiakes) have been used in 
Eussia. They are very strong and slow of absorption, and seem to 
have had a special claim for consideration as sutures in operations for 
hernia, etc., in which it is desirable to maintain their retentive power as 
long as possible. The present method of preparing catgut, its cheap- 
ness, and general desirability, however, leave no excuse for the con- 
tinued employment of tendons as either ligatures or sutures. 

Post-operative Antisepsis. — In the presence of an aseptic wound 
there is nothing to do but to restrain the curiosity. Where there is no 
febrile reaction, no pain in the wound, no pulsation in the seat of oper- 
ation, it is safe to leave the wound alone until the eighth day. If 
buried animal sutures have been employed, the dressings can be left 
on with saftey from ten to fourteen days. If, however, interrupted 
nonabsorbable sutures have been employed, the dressings should be 
taken down not later than the eighth day with the object of removing 
any sutures that may threaten to do mischief. When, however, the 
patient has fever and complains of pain and throbbing in the wound, 
which shows a tendency to increase rather than to subside, the dress- 
ings should be taken down and the wound should be reopened at any 
point that may be indicated by redness or tension. Pus will thus be 
revealed. When this occurs, particularly in a hospital, it should be 
accepted as a circumstance of serious importance, threatening alike the 
lives of other inmates and the reputation and usefulness of the insti- 
tution itself. A pus case may be the focus of an infection that, in the 
absence of an intelligent discipline thoroughly enforced, may result in 
the infection of the entire institution. More than one hospital is thus 
thoroughly infected, the surgeons in charge wondering why they can 
no longer secure aseptic results. The micro-organisms of pus are hid- 
den foes that may lurk anywhere that can be touched by infected hands, 
to be carried thence by other hands to infect yet uninfected fields. To 
avoid this calamity, a pus case should be isolated by being put into a 



ANTISEPSIS 69 

room by itself in charge of a special nurse, under the care of a special 
interne, neither of whom should be allowed to come in contact with 
noninfected cases. Dressings should be removed with the utmost care 
to protect the bedclothing and the patient's garments, to say nothing of 
the nurse's hands, from contamination. Long dressing forceps should 
be used, and dressings or sponges employed in the course of the case 
should be deposited in a large granite basin. 

The Surgeon. — The antiseptic precautions to be observed by the 
surgeon devolve with equal force upon his assistants, including the 
nurse. The surgeon, to begin with, should possess the instinct of clean- 
liness, or else he should be deprived of his license to practise. The suc- 
cess of the surgeon in aseptic surgery is directly proportionate to the 
extent to which he possesses this instinct and is actuated by it; it must 
be the dominating impulse of his work, and no amount of technical 
training can entirely make up for its absence. Important as is this in- 
stinct, it needs to be directed by intelligence and crystallized into 
habit. The discipline necessary for this purpose is a severe one. It 
has its beginning in habits of personal cleanliness, including frequent 
bathing, repeated ablutions of the hands, and painstaking supervision 
of the finger nails; but the exactions of surgical asepsis require even 
more than this. 

Hand sterilization has been, and remains, one of the perplexing 
problems of the new regime. The fact that various micro-organisms, 
notably the Bacillus epidermidis albas, find their way into the deeper 
epithelial folds of the skin, where they are beyond the reach of chem- 
ical antisepsis, has furnished the chief difficulty. The method of 
hand sterilization at present practised by the majority of surgeons is 
as follows: The hands are soaked for a period of twenty minutes in 
soapsuds, made of sterilized soap. The ablutions extend to the elbow 
and are associated with friction with a stiff brush, preferably of vege- 
table fibre. At the expiration of this time, the water having been 
changed repeatedly, the plug is taken from the bottom of the wash- 
stand and the hands and arms are washed for another period of five 
minutes with a fresh sterilized brush under a stream of running 
tepid water. The direction in which the friction should be applied is 
of importance, it being essential that the brush should be moved in 
the direction of the cutaneous folds. The hands are now washed in 
either ether or alcohol, which should be fresh. The habit of some 
hospitals of saving alcohol used for hand washing is not only of ques- 
tionable economy, but is a proceeding only a trifle less filthy than sav- 
ing wash water. After the ether or alcohol bath the hands are rubbed 
for a few minutes in a solution of l-to-2,000 mercuric bichloride. 

Another method of hand sterilization, introduced by Schatz, of 
Eostock, consists in the usual preliminary washing, as already de- 
scribed; the hands are then immersed for several minutes in a saturated 
solution of potassium permanganate; they are then washed in a satu- 
rated solution of oxalic acid, after which, chiefly to remove the yellow 



70 A TEXT-BOOK OF GYNECOLOGY 

staining induced by the permanganate and but slightly modified by the 
oxalic acid, the hands are washed in limewater, or preferably in hydro- 
gen peroxide. The hydrogen peroxide is used by Warren, of Boston, 
and may be said to be the redeeming feature of the entire formula, as 
it possesses not only cleansing but antiseptic properties vastly in excess 
of the other ingredients. 

In cases in which the hands have become unexpectedly contami- 
nated by being immersed in live pus, and in which it is necessary to 
proceed to a succeeding operation under otherwise aseptic surround- 
ings, the question of immediate hand sterilization becomes an exceed- 
ingly important one. Under these circumstances, after carefully wash- 
ing and rinsing the hands, they may be bathed in ninety-eight per cent 
carbolic acid for a few seconds. This agent is naturally an escharotic, 
but the epithelium is sufficient to resist its action for the brief time 
involved in its application, after which it is thoroughly neutralized by 
washing the hands in pure alcohol. Eeed has repeatedly adopted this 
measure with satisfactory results. Sanger (C entralblatt fur Chirurgie), 
after thoroughly washing his hands, immerses them in a warm solution 
of from two to five per cent of hydrochloric acid, and then in a one- 
half to two-per-cent solution of permanganate of potassium. The dis- 
coloration thus produced is removed by a bath of sulphurous acid. 
The chemical changes resulting from the contact with these different 
agents cause, among other things, the liberation of free chlorine, oxygen, 
and sulphurous-acid gas, all of which possess germicidal properties in 
high degree. Bacteriological studies of this method and its results by 
Kronig and Paul confirm its usefulness. Chlorine gas is a most val- 
uable disinfectant for the hands; and a convenient method of its appli- 
cation, popularized by Weir, is to wash the hands with a chloride-of- 
lime paste for a few minutes, subsequently rinsing them in sterilized 
water. With all of these methods, however, some failures are reported, 
showing that hand sterilization by chemical means has not attained per- 
fection. 

To obviate the results following on what seems to be an insur- 
mountable difficulty, the expedient has been hit upon of operating with 
covered hands. Gloves have been introduced by Halstead and Mikulicz, 
to the latter of whom is probably due the credit of establishing their use 
in a systematic way. Cotton and silk gloves have been used, but Lockett 
(Philadelphia Medical Journal, February 11, 1899) has demonstrated 
that permeable gloves become speedily saturated with micro-organisms, 
which observations have been confirmed by Pfahler. Thin rubber 
gloves are now made that are impermeable, that interfere but slightly 
with sensation, and that are capable of complete sterilization by boiling. 
After they have been worn a few times they seem to offer no serious 
impediment to dexterity. In speaking of their use, Kocher (Philadel- 
phia Medical Journal, June 10, 1899) advises as follows: "Avoid touch- 
ing with uncovered hands any infective or septic material oetween 
the operations, or wash it carefully away at once, cut your nails as short 



ANTISEPSIS 71 

as possible, brush your hands thoroughly with hot water, soap, and alco- 
hol (85 to 95 per cent), avoiding any poisonous disinfectant before you 
operate, and, if you wish to be very careful, put on cotton, silk, or, better 
still, rubber gloves when you touch the threads for ligatures and sutures, 
and when you have to tear the tissues much and to rub your fingers in 
the depth of a wound." 

A pan filled with a strong bichloride solution, or. still better, a 
paper receptacle, such as a cornucopia, should be used to receive the 
soiled dressings, receptacle and all being burned at the conclusion of 
the seance. 






CHAPTER IX 

SHOCK 

Definition — Pathology — Causes — Symptoms — Diagnosis — Treatment : Prophylac- 
tic, restorative. 

Shock is an inhibition, more or less profound, of practically all of 
the vital functions, due to defective vasomotor nerve control and char- 
acterized by diminished cardiac force, lessened arterial tension, embar- 
rassed respiration, muscular relaxation, the more or less complete 
arrest of glandular activity, and mental lethargy, verging in the later 
stages into delirium. 

Pathology. — Shock must manifestly be regarded as a neuroparal- 
ysis, in which there is evident fatigue or exhaustion of the nerve cen- 
tres, the result of profound and generally sudden irritation of some 
part of the sympathetic nervous system. This irritation may be phys- 
ical, as in the case of a blow over the solar plexus, or it may be mental, 
as in the frequent examples of intense fright. 

Causes of Shock. — Pain and fright, as already indicated, may be 
causes of shock. Every operator of extensive experience has seen cases 
in which the symptoms of shock were more pronounced before the oper- 
ation began than after it was concluded, the cause evidently existing 
in the extreme apprehensions of the patient. In abdominal and pelvic 
surgery, shock is of such frequent occurrence that its causes, under 
such circumstances, are worthy of special consideration. According to 
the brilliant investigations of Dr. George W. Crile, of Cleveland (Ameri- 
can Gynecological and Obstetrical Journal, 1898), which are confirmed 
in practically every detail by clinical experience, we learn that, even 
under profound anesthesia, the symptoms of shock may be induced by 
(a) opening the abdominal cavity; (b) the mere exposure of the abdom- 
inal viscera to the atmosphere, the profoundness of the shock varying 
inversely to the temperature of the air; (c) manipulation of the peri- 
toneum and underlying organs, the intensity of the shock increasing 
as the manipulations extend from the pelvis to the diaphragm; (d) 
disturbance of local splanchnic vasomotor areas; (e) pressure upon 
important splanchnic veins, especially upon the vena cava; (/) hemor- 
rhage to a degree sufficient to lessen circulatory tension. Phenomena 
of shock are induced more readily in youth and old age. 

Symptoms of Shock. — Shock is characterized by the sudden onset of 
symptoms, the most pronounced of which is general physical depres- 
72 



SHOCK 73 

sion. The surface becomes blanched; the features are pinched and 
distorted, sometimes beyond recognition; the cutaneous temperature is 
lowered; the hands and fingers are shrunken and the nails are of a 
bluish colour; the pulse becomes feeble and accelerated; the respiration 
irregular; the muscular tone is diminished; the sphincters frequently 
are relaxed; the patient becomes faint, lethargic, and often drifts into 
unconsciousness. In this condition there is an arrest of ail secre- 
tory and excretory functions. These symptoms, in the aggregate, are 
generally of short duration. If they become more intense they speed- 
ily terminate in death; if reaction sets in, the respiration improves, 
normal colour returns to the skin, in which the transpiratory function 
shows evidence of re-establishment, the heart improves in force and 
rhythm — probably the initial change in the return to the normal state 
— and the mental functions resume their sway. 

Diagnosis of Shock. — The diagnosis of shock is made primarily 
upon the consideration of the foregoing symptoms. It is important, 
however, to distinguish it from several conditions with which it is fre- 
quently confused. Hemorrhage presents many symptoms in common 
with shock. In hemorrhage, however, there occur, as distinctive fea- 
tures, an anxious but intelligent expression of the face; extreme rest- 
lessness, manifested especially by tossing about of the arms; and fre- 
quent attacks of syncope, in the intervals between which the patient 
regains consciousness. To the experienced and attentive observer, one 
of the most characteristic symptoms of hemorrhage is a pulse of in- 
creasing frequency with diminishing force and volume, imparting to 
the sense of touch the impression that the heart is working without 
appreciable resistance. Acute septic poisoning in its symptomatology is 
often confused with shock. These cases occur especially in abdominal 
surgery, and their proper diagnosis depends upon, first, the fact that 
they have been preceded by circumstances of, at least, possible septic 
infection; next, the gradual development of the symptoms; and, thirdly, 
the temperature range, which in the earlier stages is generally char- 
acteristically vacillating, but later runs very high. In these cases the 
temperature of the surface may be subnormal, while that which is regis- 
tered, either in the mouth, the rectum, or the vagina, may reach 104° 
F., or even higher. The majority of cases of " insidious shock " and 
of " delaj^ed shock " belong to this class. Syncope, or fainting, is re- 
garded by some as a form of shock. According to Warren, however, it 
is to be regarded simply as an acute cerebral anemia, the essential symp- 
toms of which — namely, preliminary nausea, ringing in the ears, and 
dizziness, followed by a fainting fit during which the patient is tem- 
porarily unconscious — distinguish it from shock. Emboli of various 
sorts produce symptoms analogous to shock; thus, Warren states that 
acute suppurations in tissues rich in fat may produce fat emboli, by 
which it is implied that the fluid fat liberated by the suppurative pro- 
cess may be taken up by the lymphatics and carried by them into the 
circulation. These emboli are most frequently deposited in the lungs. 



74: A TEXT-BOOK OF GYNECOLOGY 

From this locus they are generally reabsorbed and distributed to vari- 
ous parts of the system. When large amounts of the fat, however, accu- 
mulate in the lungs, it may induce alarming symptoms or death. " The 
symptoms of this complication," says Warren, " which occurs within 
twenty-four or forty-eight hours after an injury, are sudden pallor, 
irregular heart action, dyspnoea, perhaps hemoptysis, or convulsions and 
death. Fat will be found in the urine." Air embolism consists of the 
introduction of air into the veins. In small quantities air in the veins 
produces no injury, but when, according to Hare, a pint or more of it 
is introduced into the circulation, it proves fatal. Under these circum- 
stances the heart becomes filled with air and can not contract, when 
death, attended with symptoms of syncope, is instantaneous. 

Treatment of Shock. — The treatment of shock resolves itself into 
(a) prophylactic, and (b) restorative. 

The prophylactic treatment of shock should be carefully considered 
in all cases in which patients of lowered vitality are about to be sub- 
jected to surgical operations. In such cases the prolonged fasting and 
violent catharsis, frequently practised in preparing a patient for oper- 
ation, are calculated to still further reduce the strength and should be 
avoided. To such patients a mild cathartic may be given with advan- 
tage, although in extreme instances it is better to rely upon enemas 
to evacuate the bowels. The usual fast preceding the operation should 
also be omitted, and the patient be given a free liquid diet of milk, 
if well tolerated, or, still better, of bouillon, or of chicken broth, given 
hot, to within a few hours before the operation. As a rule, under such 
circumstances, alcoholic drinks of whatever variety are damaging alike 
to the stomach and the general system, and should be avoided. After 
the patient has been placed upon the table, and during the period be- 
tween preliminary unconsciousness and surgical anaesthesia, eight 
ounces of normal salt solution should be injected under each mammary 
gland. This practice of hypodermoclysis is adopted by Eeed, as a 
matter of routine, in all cases of extreme debility, or in which there is 
reason to expect considerable hemorrhage during the ensuing opera- 
tion. A small dose of a sixtieth of a grain of strychnine may be given 
hypodermically at this time, or even earlier. Injections of large 
quantities of normal salt solution into the rectum, just preceding an 
operation, while theoretically of value, generally prove worthless, as 
they are usually expelled before any considerable quantity can be 
absorbed. Special care should be taken in debilitated cases to keep the 
extremities warm, to protect the patient from currents of air, and to 
have the temperature of the operating room as high, at least, as the 
normal bodily temperature. Another prophylactic measure of impor- 
tance is Turck's rubber sack filled with hot water and introduced into 
the abdominal cavity during an operation (Fig. 26). 

The restorative treatment of shock consists in bringing every avail- 
able influence to bear upon the re-establishment of the inhibited vital 
functions. As the sympathetic nervous system seems to be the pri- 



SHOCK 



mary factor in producing those phenomena which, in the aggregate, 
we call shock, it is imperative that its functions be re-established as 
speedily as possible. With this object in view, heat should be applied, 
both over and within the stomach. A hot-water bag, a hot stove lid, 
carefully wrapped, or any other 
heated object, not too heavy, 
should be applied over the region 
of the solar plexus. To apply heat 
within the stomach, recourse may 
be had to Turck's intragastric 
resuscitator (Journal of the Amer- 
ican Medical Association, January 
11, 1896), which is constructed on 
the principle of a recurrent cathe- 
ter. This is introduced into the 
stomach, which is then subjected 
to continuous irrigation with hot 
water at a temperature of 130° F. 
Heat should be applied to the ex- 
tremities. For this purpose flan- 
nels wrung out of hot mustard 
water are of value. Friction ap- 
plied to the extremities may be 
practised, but is of less value than 
moist heat associated with mild 
cutaneous irritants. Among the 
remedies valuable in these cases 
are to be mentioned amyl nitrite, 
given by inhalation, and nitro- 
glycerine, one one-hundredth of a grain, given hypodermically, both of 
which are almost instantaneous in their results. They are equally 
evanescent in their effects, which may be made more permanent by the 
coincident administration of strychnine, one-twentieth of a grain; but 
this latter remedy should not be repeated in less than an hour, as its 
lethal effects may be induced by a comparatively small dose in cases 
of shock. Crile found that the aqueous extract of suprarenal capsules 
of sheep caused an immediate and marked rise in blood pressure, which 
effect was evanescent, the fall being as rapid as the rise. In view of 
the urgent necessity for oxygen in these cases, Crile esteems artificial 
respiration as of undoubted importance, and has recorded observations 
of its salutary effect upon the vasomotor and heart action, and hence 
upon blood pressure. 

Normal salt solution, injected in large quantities under the skin, or 
thrown directly into the veins, is a remedy of extreme value in the 
treatment of shock, particularly when associated with hemorrhage. 
The solution is prepared by dissolving a drachm of chloride of sodium 
in a pint of water. In the absence of the chemically pure chloride of 




Fig. 26. — " Another prophylactic measure 
is Turck's rubber sack rilled with hot 
water and introduced within the abdom- 
inal cavity."— Reed (page 74). 



76 A TEXT-BOOK OF GYNECOLOGY 

sodium, common table salt may be employed, and while it is always 
desirable to use sterilized water, these cases are generally of such emer- 
gency and occur under such circumstances that it is not practicable 
always to secure even water sterilized by boiling. Locke has suggested 
and reported favourably upon the use of a solution prepared according 
to the following formula: 

J$ Calcium chloride 3f grains; 

Potassium chloride 1 \ grain; 

Sodium chloride 2J drachms. 

Sterilized, distilled, or tap water, sufficient to make one quart. 

This solution is used either for hypodermoclysis, for enteroclysis, or 
for intravenous infusion. Schiicking, of Pyrmont, acting upon the 
principle that paralysis of the heart after great loss of blood is always 
associated with, if not dependent upon, the accumulation of C0 2 in the 
tissues, sought some combination which would neutralize this gas. 
The task of eliminating the C0 2 under normal circumstances is al- 
lotted to paraglobulin, the alkaline compound proteid of the blood, and 
Schiicking assumed that saccharate of sodium might take its place, inas- 
much as this compound is split up by C0 2 into sugar and sodium car- 
bonate, thus fixing the C0 2 . He therefore employs the saccharate of 
sodium in the form of a 0.03-per-cent subcutaneous injection with 0.6 
per cent of salt, and reports success with its use (250 grammes) after an 
alkaline salt solution had proved useless. The addition of albumen or 
serum or other organic elements to the fluid is both unnecessary and 
dangerous. Transfusion of blood from one person to another has be- 
come almost obsolete since the practical value of the normal salt 
solution has become understood. 

Subcutaneous infusion of normal salt solution (hypodermoclysis) 
may be practised by inserting beneath the mammary gland, or deep into 
any area of loose cellular tissue, the sterilized needle of an aspirator, 
attached either to an ordinary Davidson's syringe or to a fountain syr- 
inge. Elaborate special apparatus for this purpose is totally unneces- 
sary in the hands of an operator who is familiar with the technique of 
asepsis. From six to eight ounces of the solution should be gently and 
gradually injected. The tumour which rapidly develops by the accu- 
mulation of the fluid, should be subjected to gentle friction, which seems 
to facilitate the diffusion of the fluid. The infusion can be made 
under both breasts at the same time, or, for that matter, even into other 
areas. Care should be taken to avoid throwing a considerable volume 
of fluid immediately beneath the integument, or where the skin is not 
provided with an ample cushion of underlying cellular tissue, as the 
pressure that may otherwise be induced may cause superficial destruc- 
tion of the skin. 

Subcutaneous infusion is so readily practised and is so destitute 
of danger that it should be accepted as the operation of choice, as 
against intravenous injection, in all cases in which the shock is not 



shock 77 

profound, or the hemorrhage has not been excessive, or in which delay 
of from fifteen to twenty minutes may be indulged before the fluid 
finds its way into the circulation. 

Intravenous infusion of normal salt solution is practised by open- 
ing one of the superficial veins of the forearm. This is done by com- 
pressing the vein until it becomes distended with blood; a small inci- 
sion is then made through the integument until the vein is reached. 
This is then picked up by means of a grooved director, and two ligatures, 
half an inch apart, are placed in position. The distal ligature is then 
tied; a small opening is made into the vein between the two ligatures; 
through this opening a small blunt-pointed trocar is introduced into the 
lumen of the vein to a point above the location of the proximal liga- 
ture, which is now tightened around both the trocar and the vein. 
Care should be taken before inserting the trocar to see that it is filled 
with water from the syringe or reservoir with which it is connected. 
After the trocar has been inserted into the vein and the ligature has 
been tightened around it, the fluid is permitted to flow into the vein. 
This fluid should not be permitted to fall to a temperature below 100° 
F., and it should be used from a graduate or some other reservoir by 
which its quantity may be determined. Not less than eight ounces 
should be inserted at one time in the case of shock, while a quantity 
equal to or slightly in excess of the amount of blood lost, should be 
injected in case of hemorrhage, but not until the bleeding vessel has 
been tied. (See Treatment of Hemorrhage.) 

Rectal Infusion (Enterodysis). — Cases may occur in which it is not 
convenient at the moment to practise either intravenous or subcutaneous 
infusion because of the absence of the necessary apparatus, while there 
are other cases in which the loss of blood has been so great, and the 
shock is so profound, that it is desirable to employ not only the fore- 
going expedients, but any auxiliary to them. Under these circum- 
stances a considerable quantity of the normal salt solution, heated to 
110° or 115° F., may be thrown into the rectum. More than six or 
eight ounces should not be employed, as overdistention of the bowel 
will defeat the purpose of the injection by causing a rejection of the 
fluid. If, however, it is desired to use a greater quantity, it should be 
given as a high enema. This is done by placing the patient upon the 
left side, with the legs flexed and the hips elevated, and permitting 
from a quart to a half gallon of the fluid gradually to enter the ali- 
mentary canal. This is not only an effective way of applying heat, but, 
by bringing the fluid in contact with the powerfully absorbent surfaces 
of the colon, the procedure becomes an effective way of reaching the 
circulation. 



CHAPTEE X 

HEMORRHAGE AND HEMOSTASIS 

Hemorrhage, obvious and concealed — Symptoms— Diagnosis — Treatment: Hemo- 
stasis, styptics, heat, pressure, angeiotripsy, electro-hemostasis, ligatures. 

Hemokkhage may be studied under the head of (a) obvious, and (&) 
concealed. Obvious hemorrhage may be, in origin, both internal, as 
in metrorrhagia, and external, as in operations. Concealed hemor- 
rhage, on the other hand, is always internal, as, for instance, in rupture 
of a tubal pregnancy or a slipped pedicle in ovariotomy. 

Symptoms of Hemorrhage. — When hemorrhage is obvious — i. e., 
when there is an external flow, whatever may be the origin of the blood 
— the mere presence of the latter is all that is necessary for diagnosis, 
except, perhaps, in the instance of sanguineous discharges from the 
uterus. Under these circumstances it is sometimes important to dis- 
criminate between the menstrual flow and hemorrhage from other 
causes (see Menstruation). The question of internal hemorrhage, how- 
ever, is one which demands solution in the light of symptoms other 
than an obvious discharge of blood. Hemorrhage rarely, if ever, occurs 
without occasioning discomfort, amounting in cases to acute pain in 
the locality in which it occurs. Pain is, therefore, to be regarded as 
the usual initial symptom, particularly in all cases of vascular rupture. 
There is generally so much pain present, following an intrapelvic oper- 
ation, that the slipping of the pedicle, for example, would give rise to no 
conscious sensation, unless by the relief of the pressure there occurred 
some amelioration of the pre-existing discomfort. The pulse is accel- 
erated from the first, but the acceleration increases coincidently with 
the duration of the hemorrhage. With the increased frequency of the 
heart beat there is a progressive diminution in the volume and tension 
of the pulse. The temperature speedily becomes subnormal. The res- 
piration, at first but slightly disturbed, speedily becomes frequent and 
irregular, the patient sighing in her efforts to secure enough oxygen 
to neutralize the rapidly accumulating carbonic dioxide in her system. 
Irregular muscular activity is noted; the lips become livid and the 
finger nails blue; there is general pallor of the face and of the mucous 
surfaces; the skin becomes bathed in perspiration; strange sounds are 
heard and muttering delirium ensues, in the midst of which the pa- 
tient's eyes become staring; the alas of the nose become dilated; the 



HEMORRHAGE AND HEMOSTASIS 79 

features become pinched, until collapse, unconsciousness, and death, 
close the scene. 

Diagnosis of Hemorrhage. — (See Diagnosis of Shock.) 

Treatment of Hemorrhage. — The treatment of hemorrhage, classi- 
fied inversely to its importance, is both (a) constitutional, and (b) local. 
Constitutional measures must be addressed to the conservation of the 
remaining circulatory medium, to the relief of the practically always 
concomitant symptoms of shock, and finally to the speedy restoration 
of the volume of the blood. Practically all these measures are con- 
sidered in detail under the head of Treatment of Shock, which should 
be read in this connection. 

The local treatment should be based upon the general surgical 
axiom to " cut down and tie the bleeding vessel " in the presence of 
concealed hemorrhage of a degree sufficient to cause constitutional 
symptoms. The more profound the shock, the more imperative is this 
decree, the operation of which may in certain instances result in surgi- 
cal intervention for the relief of hemorrhage capable of spontaneous 
arrest. This is exemplified in hemorrhages into the broad ligament, 
which, through the joint influence of the peritoneal investment and 
the formation of hemorrhagic infarcts, may come to a spontaneous ter- 
mination, resulting ultimately in the absorption of the clot. These 
cases, which will be considered more in detail in connection with 
ectopic pregnancy, and which serve as the most favourable examples of 
concealed hemorrhage, are more safely treated, as a rule, by operation. 
In superficial hemorrhage, where the bleeding vessel is accessible, it 
should be brought under immediate control by some of the various 
expedients to be considered under the head of hemostasis. 

Hemostasis. — Control of hemorrhage was one of the most perplex- 
ing problems in the early development of gynecologic surgery. The 
earlier mortality tables exhibit what to-day would be looked upon as 
an alarmingly high percentage of deaths from hemorrhage. The pres- 
ent resources, however, are so adequate, that a death from hemorrhage 
under ordinary circumstances places the surgeon upon the defensive. 
Hemostatic measures may be considered under the heads of (a) styptics, 
(h) heat, (c) pressure, (d) electro-hemostasis, (e) ligatures. 

Styptics. — Styptics consist of those remedies which exercise an as- 
tringent effect upon the tissues to which they are applied. Practically 
all the mineral astringents possess more or less styptic properties. 
Sulphate of iron, sulphate of zinc, acetate of lead, and sulphate of 
copper, are examples in point. All vegetable preparations possessing 
styptic properties depend for their activity upon the presence of tannin. 
Extract of the suprarenal capsule applied to oozing surfaces exercises 
an instantaneous influence over capillary hemorrhage. Among the 
most valuable of styptics, and the more valuable because it is prac- 
tically always at hand, is dilute acetic acid in the form of commercial 
vinegar, such as is found in almost every household. This may be 
applied pure, or in the form of a douche, one part of vinegar to four 



80 A TEXT-BOOK OF GYNECOLOGY 

parts of water, or gauze may be saturated with it and packed into a 
bleeding cavity. Any vessel, the hemorrhage from which occurs in the 
form of an intermittent jet, is too large to be intrusted safely to a 
styptic. 

Heat. — Heat is a hemostatic of broad application in abdominal and 
pelvic surgery. Its use is based upon the fact that it has the effect 
of constricting the blood vessels subjected to its influence, or in higher 
degrees of temperature it may desiccate and even char the tissues. 
When heat is so great as to immediately destroy the continuity of 
structure, it does not control hemorrhage from vessels of larger calibre. 
In metrorrhagia, or in intrauterine oozing following operations within 
the cavity of the uterus, it is a valuable remedy when applied in the 
form of an intrauterine douche. To be effective, the temperature should 
be not less than 115° F., and the application should be continued for 
not less than fifteen minutes. Hot sponge packing is an exceedingly 
valuable expedient in controlling diffuse capillary oozing in intrapelvic 
and other operations. Sponges, or, for that matter, the gauze napkins 
now almost universally employed, should be wrung out of water at a 
temperature of not less than 120° F., and immediately placed in con- 
tact with the oozing surface. They should be left there for several 
minutes — long enough to secure the secondary effect of heat upon the 
capillaries. For this purpose sponges are better than the gauze, be- 
cause they possess elastic properties, which increase the pressure, also 
a valuable element in the control of bleeding. 

The actual cautery is one form of the application of heat for the 
control of hemorrhage. Irons variously shaped and fitted into handles 
are heated and applied to the bleeding surface. Keith caught the 
pedicle of a fibroid tumour in a nonconducting clamp, and then by 
means of hot irons heated to a red glow, and persistently applied for 
several minutes, reduced the stump to a state of complete desiccation, 
rendering the hemostasia absolute. Paquelin's thermocautery is merely 
a more convenient form of the old actual cautery. It consists of vari-' 
ous shaped platinum tips, hollow, containing coils of platinum wire, 
and communicating with a reservoir containing benzole. Over this 
chamber of benzole a current of air is passed, creating a combustible 
vapour, which is burned in the hollow platinum point of the instru- 
ment. By regulating the pressure upon the bulb the heat can be cor- 
respondingly regulated. The instrument is vastly more convenient 
than the, old irons, which have become practically obsolete. 

Pressure. — Actual pressure may be exerted by the fingers or thumbs 
placed upon a bleeding vessel. Elastic pressure is practised by encir- 
cling a bleeding part with an elastic ligature, stretched to a degree 
of considerable tension, and secured either by a knot or catch forceps. 
These should be recognised merely as temporary expedients, as it is 
manifestly impossible to sustain the former for long, while the latter 
soon induces tissue necrosis from pressure. Forcipressure is practised by 
seizing the bleeding vessel with a forceps. This principle has been 



HEMORRHAGE AND HEMOSTAS1S 81 

recognised in surgery from antiquity, but it was left for Koeberle and 
Pean to devise the useful instruments now known, respectively, by 
their names (see Armamentarium). It may be said without contradic- 
tion that the introduction of this instrument, for they are practically 
the same, has added vastly to the usefulness of surgery. It has been 
variously modified into long and short, thick and thin, straight and 
curved, light and heavy, but the principle involved is the same in all 
of them. The forceps consists, essentially, of two scissorlike blades, the 
distal extremities of which are arranged into serrated, approximating 
jaws, while the proximal ends are arranged with the usual scissor- 
handle rings and an intervening catch to admit of regulated pressure 
and fixation. The hemostatic forceps is usually applied for the imme- 
diate and temporary arrest of hemorrhage. In very small vessels, as, 
for instance, in the abdominal incision, the pressure thus exercised is 
sufficient permanently to control the bleeding; while in larger vessels a 
ligature should be applied before the forceps is removed. For this 
purpose a forceps of relatively thick jaws and tapering to a sharp point 
is desirable, as it permits the ligature to slide readily upon the vessel. 
In certain localities it is not practicable to apply a ligature to control 
the hemorrhage, under which circumstances the forceps is left in situ 
for a period of not less than twenty-four hours. It occasionally hap- 
pens that the tissues in the field of operation are so friable that they 
will not resist the pressure of a ligature, when continuous pressure by 
the forceps becomes essential. 

Angeiotripsy. — The angeiotribe, or pressure forceps, is an instru- 
ment designed to do away with the use of ligatures or retention forceps 
in removal of the uterus, and in extirpation of the tubes, ovaries, and 
tumours having suitable pedicles. It is founded upon the surgical 
principle of preventing hemorrhage by the formation and retention of 
blood clot. It may be used in both vaginal and abdominal section, but 
not upon omental and like fragile tissue. It is presented in many 
forms, all having the same mechanical purpose, but differing in the 
application of the force principle. The pressure is obtained by means 
of the accurate adjustment of blades to which a pressure of three 
thousand pounds is imparted by the mechanism of the handles. Tuffier 
employs screw pressure; Doyen and Thumin the lever; and there are 
other modifications of both these principles in use. 

The cut (Fig. 27) shows the Newman angeiotribe furnished with 
both lever and screw as adjustable attachments, and designed for both 
vaginal and abdominal work. (See chapter on Panhysterectomy.) The 
method of its employment is illustrated in vaginal hysterectomy. The 
operator proceeds as usual until the uterus is freed from its anterior 
and posterior attachments, including all adhesions, and remains sus- 
pended only by the broad and round ligaments. The left broad liga- 
ment is now hooked down by means of the left index and middle fingers 
or a large blunt hook of the Eastman variety, and included in the bite 
of the angeiotribe. An assistant steadies the instrument while the 
7 



82 



A TEXT-BOOK OF GYNECOLOGY 



screw is adjusted to the requisite pressure and allowed to remain for one 
or two minutes. While the instrument is in situ the ligament is divided 
with scissors between clamp and uterus, leaving a margin of say a half 

centimetre of tissue, constituting 
a small, neat stump, of ribbonlike 
thinness. This dissection re- 
leases the uterus from its attach- 
ments upon the left side, and it 
is a simple matter to draw it 
down outside the vulva, so as to 
expose the right ligament. The 
clamp is now best applied from 
above downward, and the liga- 
ment is cut as on the opposite 
side. 

When the instrument is re- 
leased for the last time and re- 
moved, careful toilet and inspec- 
tion of the entire field of opera- 
tion are made, and the sterilized 
gauze packing used in the cus- 
tomary manner, or a running 
catgut suture, including peri- 
toneal and vaginal surfaces, 
closes the vaginal vault, catch- 
ing up the contracted stumps in 
each angle of the wound. The 
external dressings are applied as 
usual, but the after-treatment is 
greatly simplified, as there are no 
retention forceps to be watched 
and removed, and no ligatures to 
come away. 

There is little or no pain, and 
the comfortable condition of the 
patient after recovery from anaesthesia is in marked contrast to suffer- 
ings of other patients under the retention clamp method. 

When it is found difficult to secure the entire broad ligament at one 
application the angeiotribe may be applied twice upon each side, com- 
pressing first the lower half of the left ligament, including the uterine 
artery, then the same area upon the right side. With the lower half of 
the broad ligament cut free of the uterus, the upper half can usually 
be easily drawn down by the fingers or broad ligament hook, and the 
clamp applied upon its remaining portion containing the ovarian 
artery. 

Another method, and one which Newman frequently uses, consists 
in applying temporarily to the base of the ligament the ordinary clamp 




Fig. 27.—" The Newman angeiotribe furnished 
with lever and screw." — Newman (page 81). 



HEMORRHAGE AND HEMOSTASIS 83 

or ligature, catting this portion, inverting the uterus forward out of 
the anterior peritoneal opening, and applying the angeiotribe on each 
side from above downward the entire width of the broad ligament, in- 
cluding the stump of the previously clamped or ligated base. 

The dry pack is another means of applying pressure, especially 
within the peritoneal cavity, the cavity of the uterus, and the vagina. 
Within the peritoneal cavity, the method of Mikulicz, who introduced 
the practice, is as follows: The cavity is lined, preferably with a pocket 
formed of iodoform gauze. Into this pocket a rope of iodoform gauze 
is st Lifted until the entire cavity is rilled. It should be packed with 
sufficient firmness to insure pressure upon the proximal bleeding sur- 
face. This practice has been modified very generally by simply pack- 
ing the bleeding cavity with a rope of sterilized gauze, without taking 
the precaution to line the cavity with a gauze pouch. Packing thus 
introduced should not be withdrawn under less than twenty-four hours; 
after this time, if the vessels are not very large, hemostasis is reason- 
ably certain. 

Electro-liemostasis. — Electro-hemostasis is in reality but another 
form of controlling hemorrhage by heat. In this instance the heat is 
generated by the electric current and is brought in contact with the 
tissues by means of the electric loop, the electric knife, the electric 
forceps, or by means of a platinum cautery tip. The same propor- 
tions should be observed in the application of electricity for hemostatic 
purposes that are prescribed for the use of heat in any other form 
applied to the control of hemorrhage. The most essential of these 
precautions are, first, to avoid the use of too high a degree of heat, and 
secondly, to protect adjacent structures from its action. 

John Byrne, of Brooklyn, was the first to popularize the galvano- 
cautery in America, and to him is due the credit of demonstrating its 
hemostatic possibilities in high amputation of the cervix for cancer. 
It can not be said, however, that this operation is the most crucial test 
to which a hemostatic measure can be subjected, for the reason that 
high amputation of the cervix can be practised as an almost bloodless 
operation, without the use of any hemostatic whatever. As used by 
Byrne, the instrument consists of a loop of platinum wire, passed 
through a noose carrier and both ends of it attached to a key, not unlike 
that of a violin, whereby the size and tension of the loop can be accu- 
rately regulated. Either end of the wire is brought into contact with 
the opposite poles of the battery, which may be either a storage battery 
or a primary battery, or the current may be taken from an electric- 
light circuit and utilized through the medium of a transformer. Fur- 
ther details of the use of the electric loop will be mentioned in connec- 
tion with vaginal hysterectomy. The electric knife consists of a smaller 
loop of platinum Avire, flattened and fixed in a nonconducting handle, 
through which it passes, and is attached to the battery. By means of 
the regulator this blade can be brought to any degree of temperature 
desired. When, however, it is utilized to pass through tissues, it must 



84 



A TEXT-BOOK OF GYNECOLOGY 



be heated to so high a degree that its hemostatic properties are rela- 
tively diminished. When using either the electric loop or the electric 
knife, the handles, of whatever material constructed, should be wrapped 
with moist, sterilized flannel, to protect the vagina from the action of 
the heat. 

Hemostasis by the use of the electric forceps is one of the most valu- 
able of our recent additions to surgery, the credit for whose invention 

belongs to the late Dr. Skene, of 
Brooklyn. It is an adaptation of 
heat and pressure, in combination, 
to the control of hemorrhage. In 
its simplest form the apparatus con- 
sists of the electric forceps proper, 
conducting cables, and a storage 
battery (Fig. 28). Instead of the 
latter, the current may be taken 
from an electric-light plug and 
passed through a transformer, 
with which the forceps, in turn, is 
connected. If the electric-light 
current is continuous, a rotary con- 
verter will be required to convert it 
into an alternating current suitable 
for operating the transformer. The 
forceps may be of various forms and 
sizes. " One jaw of the forceps is 
hollow and is heated by having a 
resistance wire located at the bot- 
tom of the chamber close to the 
face of the jaw, from which it is 
insulated by a thin layer of fire- 
proof material. The chamber above 
the wire is filled with insulating 
material, which is also a noncon- 
ductor of heat, such as asbestos, 
and is so closed by a sheet metal 
cover as to be watertight. One end 
of the resistance wire is connected 
to the jaw and the other to an in- 
sulated copper wire placed in a 
metal tube, which extends from the 
chamber along the shaft of the for- 
ceps handle to a metal block, which 
is attached near the ring end of the forceps handle. A copper wire is 
here connected to an insulated terminal mounted in the block. A 
similar terminal is attached directly to the block and is uninsulated. 
By this means of construction the electrical wires are incased in metal, 




Fig. 28. — " The apparatus consists of the 
electric forceps proper, conducting ca- 
bles, and a storage battery."— Reed. 



1 



HEMORRHAGE AND HEMOSTASIS 85 

so that the forceps can be sterilized and handled without injury, the 
same as any ordinary instrument. Starting at the insulated terminal, 
the path of the current is through the copper wire and the resistance 
wire to the tip of the jaw, thence through the blade of the forceps 
to the uninsulated terminal. The copper wire and the blade of the 
forceps form a path of good electrical conductivity, and are conse- 
quently but slightly heated by the passage of the current used. On 
the other hand, the wire in the chamber is a poor conductor and is 
heated to a greater or less degree, according to its resistance and 
the strength of the current.'' 

Before applying the electric forceps it is sterilized, just as is 
any other instrument; but care should be taken after its removal 
from the sterilizer to avoid placing it immediately into cold water, 
as the contraction thereby induced may result in destroying the 
air-tight quality of the jaw containing the insulated terminals. The 
rubber-covered end of the electrical cable is best sterilized in boiling 
water, and should then be wrapped in a sterilized towel, or immersed 
in a five-per-cent carbolic solution. A little sterilized vaseline should 
be placed on the approximating surfaces of the jaws of the instrument 
to prevent the tissues from adhering to them. 

The method of using the electric forceps consists in firmly com- 
pressing a portion of the bleeding tissue, or preferably the end of the 
bleeding vessel, between the jaws of the instrument, the object being to 
expel as much of the moisture as possible, before the electric current 
is turned on, an expedient which greatly facilitates the subsequent 
process of desiccation. The forceps is then subjected to the current, 
and by that means heated to a temperature of from 180° to 190° F., 
just enough to desiccate but not to char the tissues. 

All tissues to be treated should be firmly compressed between the 
jaws of the instrument applied cold and subsequently heated. If this 
precaution is not observed, it will be necessary to reapply the instru- 
ment, and thus consume additional time. Skene advises that before 
the electric current is turned on a piece of gauze or a shield should 
be applied, where needed, between the forceps and the adjacent tissues, 
to protect them from injury by contact with the hot instrument. The 
forceps should be left on from thirty seconds to two minutes, accord- 
ing to the thickness of the tissues or the size of its contained vessels. 
Before it is removed the tissues projecting beyond its jaws are cut off, 
and the pedicle beneath is seized with a shield or compression forceps 
to hold the stump in position for inspection. The forceps is then grad- 
ually opened and the desiccated stump is permitted to slide out from 
between the jaws in the direction of the teeth. Skene insists upon 
this precaution as one of importance. The absence of bleeding upon 
the removal of the forceps indicates that the desiccation has been suffi- 
ciently effective, and Skene assures us the stump can be left without 
fear of secondary hemorrhage. If, however, bleeding should occur im- 
mediately upon the removal of the forceps, the latter should be reap- 



86 A TEXT-BOOK OF GYNECOLOGY 

plied at once, and the heating should be repeated with about ten per 
cent more current, or for a longer time. In this way the tissues will 
become thoroughly desiccated, but not charred, and the blood vessels 
so thoroughly occluded that they can not be opened up again, either by 
blood pressure or the most critical dissection. 

Ligatures. — It is a suggestive fact that practically all accepted liga- 
ture materials are of animal origin. This remark is intended to apply 
to silk, which, being the product of the silkworm, is quite as much an 
animal as it is a vegetable product. Silk has been the material of pref- 
erence for ligature purposes for many years. It has the advantages of 
being strong, very flexible, capable of being tied in a firm knot, and 
within the peritoneal cavity it is capable of absorption by the tissues. 
On the other hand, there is much difficulty in securing a pure article, 
and its adulteration with either cotton or flax renders it incapable of 
absorption when used in intrapelvic work. It is as difficult of steriliza- 
tion as is catgut or any other of the distinctly recognised animal liga- 
ture materials. It will not become absorbed when used as a buried 
suture in the parietal tissues, and in the presence of infection it be- 
comes the nidus for the development of secondary abscesses, sinuses, etc. 
If silk is used, care should be taken to ascertain that it is pure. This 
can be done by dropping a piece of the thread into liquor potassag; if in 
the course of twelve hours it thoroughly dissolves, it may be accepted 
as pure; if shreds remain, the fact may be accepted as evidence that it 
is adulterated with either cotton or linen, and should be discarded. 
In its preparation for use it should be sterilized by boiling at a high 
degree from fifteen to twenty minutes, or subjected to steam pres- 
sure of not less than forty-five pounds to the square inch during a sim- 
ilar period, after which, for further protection, it should be kept in a 
solution of absolute alcohol containing not less than two per cent of 
carbolic acid. It can be prepared in different sizes and should be kept 
in hermetically sealed jars, through an elastic covering of which it can 
be drawn as needed. It should be remembered that silk kept in a state 
of moisture for any considerable length of time will disintegrate to a 
degree that renders it unfit for use. Catgut is a ligature material 
of great popularity, for the proper preparation of which see Antisepsis. 



CHAPTER XI 

ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 

Definitions — Anaesthetic agents — Relative safety of ether and chloroform — Race 
and temperament in the selection of an anaesthetic — Indications and contra- 
indications for the use of ether and chloroform — Ether in relation to bodily 
temperature — Choice of anaesthetic for children — Bromide of ethyl, indications 
and contraindications — Administration of ether — Of mixed vapours — Of chlo- 
roform — Of bromide of ethyl — Management of respiratory and other accidents 
— Anaesthetic mixtures — Central anaesthesia by cocaine — General anaesthesia 
by alcohol — By hypnosis — Local anaesthesia. 

Anaesthesia is a term suggested by Oliver Wendell Holmes as a 
proper one for the condition produced by the inhalation of sulphuric 
ether, and it has been universally adopted in all countries and languages 
and extended in its application, very properly, to all forms of loss of 
pain sense, whatever be the agent or cause producing this condition. It 
is natural, therefore, that all drugs capable of benumbing the sense of 
pain should be called anaesthetics. As a matter of fact, a very large 
number of substances are capable of producing this condition of 
anaesthesia, either when inhaled, when taken by other means into the 
bocly, or when acting locally on peripheral nerves; yet a great majority 
of these possess other powers which prevent us from using them — that 
is, they are lethal if not used very carefully, or irritant, or cause degen- 
erative changes in the tissues. Although more than fifty years have 
elapsed since ether and chloroform were first employed as anaesthetics, 
no other drugs have yet been discovered which even remotely approach 
them in general usefulness, notwithstanding the fact that both these 
substances possess very great disadvantages. As a matter of fact, they 
are the only two drugs generally used in surgery to-day as anaesthetics 
for major operations. It is true that nitrous-oxide gas is largely used by 
dentists, but the physician and surgeon practically never use it because 
it is too fleeting in its effects, and because the apparatus for storing it 
is costly and cumbersome. 

Anaesthetic Agents. — So far as the surgeon is concerned, the anaes- 
thetic drugs which can be satisfactorily employed are ether, chloroform, 
and bromide of ethyl, named in the order of their popularity and 
safety. While it is true that in certain parts of this country and else- 
where chloroform is used to the exclusion of ether, it is also a fact that, 
taking the world at large, ether is most widely employed. It is a note- 

87 



88 A TEXT-BOOK OF GYNECOLOGY 

worthy fact that in England and on the continent, where for many 
years chloroform was the favourite anaesthetic, ether is rapidly grow- 
ing in popularity and in the frequency of its use. Bromide of ethyl 
is so little used in comparison with these two drugs that it can scarcely 
be mentioned with them, but as it is the only one of any real value- 
besides the more important ones, it is named at this point. 

Relative Safety of Ether and Chloroform. — The bald statement can 
be made without danger of correction that, as a rule, ether is by far 
the safer anaesthetic of the two for the average case. Statistics which 
are stupendous emphasize this fact, and it is as certain as anything- 
human can be; but to make this statement without the additional fact 
that circumstances alter cases, that idiosyncrasy or disease may render 
it safer to use chloroform than ether, would be unjust to an impor- 
tant subject. That such conditions may, and in abdominal and pelvic 
surgery, especially, do exist and reverse the general rule just laid down,. 
is as certain as that general rule itself. 

Race and Temperament in the Selection of an Anaesthetic. — Upon 
the Anglo-Saxon race and those races who by close association, habit, 
and environment, are similarly affected by climate and other causes,, 
ether, as a rule, acts well, provided that it is employed properly and 
that the temperature of the atmosphere is moderately cool. The pres- 
ence of a high temperature, such as is met with in hot countries, ren- 
ders it impossible to use ether with advantage, and makes it necessary 
to use chloroform. Again, it would seem that chloroform acts better 
upon southern peoples than upon northerners, and these facts point 
an explanation for the strenuous assertions of the ether advocate and 
the equally forcible statements of the employer of chloroform. Dog- 
matic statements upon both sides of this question have done an im- 
mense amount of harm. They have clouded the judgment of the pro- 
fession, they have given medical students a bent which, once attained, 
has persisted all their lives, and finally they have led to most impor- 
tant legal complications. Hare has heard a great teacher tell his 
students that if they used chloroform, and had a death under its use, 
he would testify that the death was avoidable; and he is continually 
meeting men so influenced by those teachings of years ago that they 
do not use chloroform to-day because they are so fearful of an accident. 
This is hot good doctrine. Every one who uses anaesthetics should 
employ them according to the case to be treated, and the employment 
of either drug to the exclusion of the other is not giving the patient 
or the physician himself all the chance for good results that is due 
to them. Yet at the present time these drugs are used by habit or rou- 
tine to an extent that is unwise. There are as many reasons for using 
a given anaesthetic as a given drug in place of another, for there are 
indications and contraindications governing the use in either case. 

Indications and Contraindications for the Use of Ether and Chloro- 
form. — Beginning, then, with a consideration of the most important, 
drug — ether — and believing that it is the anaesthetic best suited to a. 



ANESTHETICS AND ANESTHESIA IN GYNECOLOGY 89 

majority of cases, what are the factors which render its use inadvisable 
in a given case ? In the iirst place, its local effect npon the upper and 
lower respiratory tract is a distinct disadvantage in all cases, and the 
presence of a pre-existing irritation in these parts renders it very often 
a dangerous anaesthetic. To it are credited the production of severe 
attacks of bronchitis, pneumonia, and pulmonary oedema, and it is 
undoubtedly responsible for these sequelae in some instances. The 
question is, How often is the irritation of the ether inhalation the real 
factor in the production of these states? Hare believes it to be very 
rarely so, except in susceptible children and old people, and in persons 
who have an idiosyncrasy to its use. In a large number of the cases the 
respiratory difficulties after etherization are due to exposure to cold, 
and very slightly, if at all, to the ether. This is a fact overlooked to an 
extent which is almost criminal in its negligence. There is not a reader 
of this chapter who has not seen patients stripped of nearly all cover- 
ing but a sheet or shirt, and exposed for a long period, while some 
great heat citadel of the body, such as the abdominal cavity, is ex- 
posed or even opened to the general air of the room. Not one of them 
but knows that the abdominal wall is the first to feel exposure, and that 
the great vessels and abdominal organs are the heat distributors and 
centres of heat in the body; and yet even in the best operating rooms, 
the abdominal cavity, the natural temperature of which is about 103° 
F., is exposed to an atmosphere, warmed, it is true, but even when at 90° 
F., still thirteen degrees colder than the belly contents. Further, the 
lumbar region, the back and the buttocks, are often lying in a puddle 
of liquid for many minutes. There are few surgeons who could them- 
selves survive such exposure without ill effect. It is true that ether 
helps the temperature to fall by its evaporation and its consequent 
abstraction of heat, by aiding the dissipation of heat by its effect 
on the vessels, and by affecting the nervous mechanism of heat regu- 
lation, but these other factors aid it also. Many years ago Hare re- 
ported a series of observations upon this subject, which showed that 
these assertions are true. 

Ether in its Relation to Bodily Temperature. — In the lower animals 
a fall of temperature under profound etherization may amount to as 
many as 8° to 10° F., and in man it is by no means uncom- 
mon to observe a fall of as much as three degrees below normal, the 
fall being influenced somewhat by the part of the body operated upon. 
In thirteen cases taken at random the greatest fall was 4.4° and 
the lowest 1.2° F. There can be no doubt that much of the renal con- 
gestion and respiratory disorder met with after operations would be set 
aside if the patient was supplied with heat during the use of the 
anaesthetic, rather than after he is put back to bed. 

Without any desire to defend ether from the assertion that its 
respiratory effects are somewhat baneful, let us then be sure that it is at 
fault in a given case before discrediting its claim to usefulness. 

Again, ether is often given in a manner which is improper in more 



90 A TEXT-BOOK OP GYNECOLOGY 

ways than one. Partly because the youthful assistant who gives the 
anaesthetic is desirous of being quick in his work, partly because his 
superior is often urging him to hurry the patient into the operating 
room, the drug is poured too freely upon the inhaler and the inhaler 
held too closely to the patient's face, with the result that the ether 
vapour comes in concentrated form upon mucous membranes not pre- 
pared to receive it, which causes a profuse outpouring {Therapeutic 
Gazette, 1888, p. 317) of secretion, accompanied with struggling and 
cj^anosis. An}>- assistant whose patient struggles in the first stage of 
the anaesthetizing process is not performing his function properly. 
The early stage should be sufficiently prolonged to produce quietly 
the so-called primary anaesthesia, and the inhaler should be gradually 
brought nearer and nearer to the patient as the effect of the drug is 
momentarily increased. By this means evil dreams or delusions in the 
later stages are often avoided. If a patient sinks into unconsciousness 
under the firm mental impression that she is being choked to death, 
the dreams that follow are not apt to be joyful. Aside from the trou- 
blesome struggling later on in anaesthesia, it should be recalled that 
the nervous shock of such a sensation and such dreaming is a severe 
strain upon the patient's nervous system. An ordinary nightmare is 
sufficiently disturbing, but a real operation added to it, preceded by a 
conscious period of fright, is a terrible combination of nerve-straining 
elements. It is for this reason in part that physicians are continually 
seeing patients who, having left the surgeon's hands as " operative re- 
coveries," are physical wrecks. 

Even if ether is given properly it may produce evil effects, as already 
stated, and in general terms it may be considered that known idiosyn- 
crasies to its effects from former accidents or sequelae, acute and chronic 
bronchitis, nephritis in all its forms, but particularly in its acute and 
parenchymatous forms, and laryngeal inflammations, render chloro- 
form the preferable drug. In all cases in which the surgeon has control 
of his patients for any length of time before the operation a careful 
examination of the urine should be made. Not only should albumin 
and cysts be sought for, but several estimations of the amount of urea 
excreted in twenty-four hours should be made, since this will oftentimes 
reveal renal inadequacy or diseases which may be exaggerated by the 
anaesthetic and cause complications which are undesirable and dan- 
gerous. 

Again, in the presence of marked atheromatous degenerations of the 
arteries, of aneurism, and abdominal inflammation, chloroform is the 
better anaesthetic, since it lowers rather than raises blood pressure and 
does not cause struggling, as does ether, and, therefore, is not so apt 
to cause apoplexy, nor is vomiting so apt to follow its use. 

On the other hand, if any dilatation of the heart or degeneration 
of its walls and severe valvular leakage is present, then ether is the 
safer drug. 

There are operative reasons for choosing one anaesthetic in prefer- 



ANAESTHETICS AND ANESTHESIA IN GYNECOLOGY 91 

ence to the other which are almost as important as those just given. 
Other things being equal, and the ansesthetizer being skilled in the use 
of chloroform, this drug is often superior to ether in that it does not so 
frequently cause vomiting, which, if severe, may be disadvantageous in 
abdominal operations. It must be borne in mind, however, that if 
proper ante-operative procedures are taken and ether is given with care 
and with oxygen, vomiting can often be entirely avoided, and ether is 
the drug of preference in the majority of cases in cool climates. 

Choice of Anaesthetic for Children. — There can be no doubt that in 
very young children ether may cause considerable bronchitis, some- 
times associated with such an outpouring of mucous liquid that a state 
approaching suffocative catarrh is developed. Chloroform, if properly 
given, does not do this. Not only is this true, but it is also a fact that 
very young children have a certain amount of immunity from the lethal 
effects of chloroform. There are few instances on record of death from 
chloroform in young children, and this fact, combined with the avoid- 
ance of respiratory irritation and the early struggling produced by 
ether, renders it wise in many instances to emplo}^ chloroform. 

Bromide of Ethyl — Indications and Contraindications. — The ques- 
tion may well be asked, Under what circumstances is it proper to use 
bromide of etlryl? Before answering this question, it must be recalled 
that this drug is even yet under a cloud, and has not reached a degree 
of popular favour which makes the uninitiated feel like trying it. 
This state of affairs depends upon several factors. In the first place, 
the early attempts made to introduce it into practice in this country 
were productive of catastrophes which frightened the surgeons using 
it sufficient^ to make them give up its emploj^ment, and incidentally 
alarmed those who had not yet attempted its use. The use of a new 
and untried drug followed by an accident would naturally impose 
upon the medical man an increased load of blame, yet the occurrence 
by coincidence of such accidents when the drug was first used, is no 
reason for condemning the drug as too unsafe to warrant its adminis- 
tration. The very fact that the ana?sthetizer did not know how best 
to give it rendered it more likely to act badly than when it was skilfully 
used, and in all probability the preparation of the drug employed may 
not have been pure. The writer has often wondered how long the use 
of ether or chloroform might have been delayed had the first patients 
placed under their influence died, a possibility by no means remote, 
because those patients might perchance have had hearts unfit for the 
use of those drugs. If, for example, Sir James Simpson's " chloroform 
party " had ended in a chloroform catastrophe, one or more of them 
never coming back to life, what an unjust blow would have been given to 
a most useful drug, and who would have felt like repeating the test! 

As a matter of fact, a certain number of deaths have been recorded 
as having been caused by bromide of ethyl (see page 95 for possible 
causes), and there can be no doubt that it is capable of causing death 
if badly given to a patient unfit for its use. The important questions 



92 



A TEXT-BOOK OF GYNECOLOGY 



are, whether it is safe enough to justify its common use, and whether 
it fulfils any indications not so well filled by ether and chloroform. 
The answer to botn these questions is in the affirmative. The drug has 
been given many thousand times without ill effects and deserves a 
place in the hands of the gynecological operator and obstetrician. Cer- 
tain perfectly proper and easily taken precautions are essential for its 
satisfactory use (see page 95). The indications for its employment 
are sufficient and numerous. The first of these is met with when we 
desire to employ a rapidly acting, agreeable, and fleeting anaesthetic 
for the performance of short operations, such as curetting and dilat- 
ing the uterus, and in making painful examinations. When properly 
given, bromide of ethyl produces anaesthesia almost as rapidly as 
nitrous oxide, and when it is stopped the patient returns to conscious- 
ness almost as speedily as when the gas is given, and without any 
nausea, vomiting, dizziness, or other ill effects. It lends itself, there- 
fore, to a large number of cases in and out of the gynecologist's office, 
and deserves greater use. There are two disadvantages connected with 
its employment — first, that there may be muscular tonic contraction 
or rigidity, which is annoying, and may render efforts at examination 
or operation difficult until it is overcome; and, secondly, that it is 
apt to leave a garlicky odour on the breath — two objections of compara- 
tively small moment, after all. The drug is not suitable for pro- 
longed operations. 

The Administration of Ether. — The anaBsthetizer, like the operator, 
knows that the simpler the instrument the easier the performance of 

the duty before him, and as a re- 
sult there are but two forms of 
ether inhalers commonly employed 
in the United States, and these 
meet the needs of the case so well 
that nothing else need be consid- 
ered. The one is the folded towel, 
turned into a well-made cone, 
stiffened, it may be, with a sheet 
of heavy paper or cardboard be- 
tween its folds, and fitted in the 
apex with a small, clean, and ster- 
ile sponge or piece of absorbent 
cotton, to hold the anaesthetic 
fluid. For this may be substituted 
the Allis inhaler, which is a cylin- 
drical or ovoid cover around a 
grated case, from the gratings of 
which layers of cotton cloth pass 
from side to side (Fig. 29). The air passes freely between the layers 
of cloth, which, being wet with ether, load the inspired air with 
ansesthetic vapour. If made of metal, so that it can be boiled after 




Fig. 29.—" The Allis inhaler, which is a cy- 
lindrical or ovoid cover around a grated 
case, from the gratings of which layers 
of cloth pass from side to side." — Hare. 



ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 93 

each use, and kept rigidly clean, this is the best inhaler on the market, 
because it gives plenty of ether and it permits a view of the face 
of the patient. Both the simple cone and the Allis inhaler can be 
employed when it is desired to give oxygen gas with the anaesthetic, 
since the gas can be delivered to the patient by means of a soft tube 
slipped under the edge of the cone close to the patient's nose. 

The Administration of Mixed Vapours for Anaesthetic Purposes. — 
There are several somewhat complex forms of apparatus on the market 
for giving ether and oxygen gas or chloroform and oxygen gas. Hare 
considers none satisfactory in every respect. In all forms which he has 
seen, the oxygen is made to bubble through the ether or the chloroform, 
thereby vaporizing the anaesthetic, and a mixture of oxygen gas and 
of the anaesthetic vapour is then conveyed through a tube to the in- 
haler, which is placed over the patient's nose and mouth. There are 
several disadvantages inseparable from this method of using this valu- 
able combination of therapeutic agents. The first objection is that it 
is impossible to increase or decrease the quantity of oxygen gas supplied 
to the patient without at the same time increasing or decreasing the 
quantity of ether or chloroform, and conversely the quantity of these 
agents can not be verified without the supply of oxygen. Manifestly, an 
inability to make suitable variations in the quantity of these various 
agents is distinctly disadvantageous. As an illustration of how disad- 
vantageous it may be, Hare mentions the fact that an eminent surgeon 
complained to him that a grave difficulty in the use of oxygen and ether 
lay in the long period of time required to get the patient under the 
anaesthetic. The cause of this delay was without doubt due to the 
fact that if large quantities of oxygen were passed through the ether 
with the purpose of conveying considerable amounts of the anaesthetic 
to the patients, the individual also received such large quantities of 
oxygen that a condition of physiologic apnoea, or shallow or arrested 
breathing, occurred through sedation of the respiratory centres. As 
soon as this sedation took place the patient breathed less deeply than 
before, or she stopped breathing entirely, and under these circum- 
stances took but little anaesthetic vapour into the lungs, and so passed 
very slowly, if at all, under its influence. In Hare's opinion, therefore, 
the proper way to use oxygen by inhalation, in conjunction with the 
anaesthetic, is to place the drum upon whatever form of inhaler the 
physician desires to employ, and to carry into the inhaler the oxygen 
gas direct from the bag, which is usually attached to the steel c}dinder 
containing the gas. Under these circumstances the patient receives 
both the anaesthetic and the oxygen, each of which can be increased 
in quantity, according to his needs, with the result that he can be 
speedily anaesthetized and yet receive all the oxygen that is necessary 
to prevent any of the disagreeable symptoms of anaesthetization and its 
disagreeable sequelae. Such a plan has the added advantage that it is 
simple and does not require any additional apparatus, the rubber tube 
from the oxygen cylinder passing under the edge of the inhaler placed 



94 A TEXT-BOOK OP GYNECOLOGY 

upon the patient's face, and the supply of gas being governed by the 
stopcock on the cylinder. 

One of the forms of apparatus which is usually sold for the simul- 
taneous administration of oxygen and ether consists in an inhaler 
which covers the patient's nose and mouth and prevents him from 
getting any atmospheric air, with the result that he is forced to breathe 
nothing but pure oxygen, mixed with anaesthetic vapour. In order to 
make this still more complete, a large rubber bag is attached to the 
inhaler, which has no connection with the outside air, and which is 
inflated with each expiration of the patient and dilated with each inspi- 
ration. After a very few respiratory movements the patient is there- 
fore receiving a mixture of oxygen anaesthetic and devitalized air, the 
quantity of the latter increasing with each subsequent respiration. 
Manifestly this method has two grave objections: First, that the pa- 
tient is supplied with pure oxygen instead of with atmospheric air, 
whereas Nature provides healthy human beings with a mixture of oxy- 
gen and nitrogen. The other disadvantage is that the patient is con- 
tinually taking back into his lungs impurities which he ought to be 
getting rid of. 

That the administration of oxygen gas with ether or chloroform is 
a distinctly advantageous procedure can not be doubted. The pulse 
under both anaesthetics when the gas is given remains in good condi- 
tion in a majority of cases, and there are no complications or sequelae 
in the shape of depressions, nausea, or vomiting. Feeble circulation 
and respiratory disorders are much less frequently met with if oxygen is 
given than if it is not administered. Further than this, the progress of 
the patient during the anaesthetic period is usually peaceable, cyanosis 
being largely avoided. 

The Administration of Chloroform. — For the administration of chlo- 
roform even more apparatus has been invented than for the giving of 
ether. Much of it is extremely complicated, possessing this disadvan- 
tage in addition to others which need not be considered in the brief 
space devoted to this article. While it is true that many of the English 
anaesthetizers employ these, American physicians are usually content 
with much simpler apparatus. There are, practically speaking, only 
two chloroform inhalers that can be generally employed with advan- 
tage — namely, that of Esmarch and that of Lawrie. Both of these 
inhalers embody two essentials of every form of apparatus used for the 
giving of chloroform — namely, the free access of air to the patient. 
All the more complicated inhalers are lacking in this important char- 
acteristic, or depend upon valves which may get out of order. The 
majority of anaesthetizers in this country employ a folded napkin or one 
of the inhalers just named. The patient should get at least ninety per 
cent of air during the use of the chloroform. Great advantages in the 
Esmarch and Lawrie inhalers are the facts that a free supply of air is 
present; too much of the drug can not be poured upon the inhaler with- 
out escaping, so that the patient can not receive an overdose, except 



ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 



95 




through gross negligence; and the face of the patient is readily seen. 
Whatever the form of inhaler used, it must never be held so tightly 
over the patient's face that air is cut off 
(Fig. 30). 

The Lawrie inhaler is so cheap that a 
new one can be used for each patient, and 
the thin flannel cover of the Esmarch 
can be boiled each time it is used, thereby 
insuring sterilization. 

AYhen chloroform is given it must 
be placed on the inhaler in drops, and 
not poured on freely as one uses ether. 

Finally, the anaesthetizer should re- 
member that the dose of the anaesthetic 
is not that which he pours on the inhaler 
so much as the amount that the patient 
takes into his lungs, and, therefore, that 
in all cases the attention of the anaesthet- 
izer should be centred on the respira- 
tion, for upon the rapidity and depth of 
this function does the close depend. 
Again, as the respiratory function is the 
first one to feel the depressing effects of 
the drug, it acts as a good index of the 
degree of influence. In a case where the 
heart is known to be diseased, this organ 

must, of course, be watched also. Should the respiratory action become 
irregular or stormy, the anaesthetizer should at once stop the anaes- 
thetic, since the irregularity indicates abnormal action of the drug, 
and the amount inhaled can not be estimated. 

The Administration of Bromide of Ethyl. — YYhen bromide of ethyl 
is given, it should be placed upon a cone or inhaler which tightly fits 
the face, and be pushed freely until the patient passes under its effect, 
which will be rapidly accomplished, as a rule. Care must be taken 
that the bromide of etlrylene is not used by mistake, and that the drug 
is kept in dark glass bottles to prevent its decomposition. In order to be 
sure of its purity, it is best to use the drug from hermetically sealed 
flasks. 

Management of Respiratory and Other Accidents in Anaesthesia. — 
Attention may be called to the use of two instruments commonly em- 
ployed by inexperienced anaesthetizers, which are nearly always, 
abused, viz., the mouth gag and tongue forceps. The mouth gag aids, 
rather than prevents, the falling of the tongue back into the mouth, and 
increases the possibility of the inhalation of saliva or other materials 
into the lungs; and the tongue forceps is almost invariably so con- 
structed that it bruises, punches, or punctures, the tongue in a manner 
that is anything but wise. Inexperienced anaesthetizers are very apt 



Fig. 30. — Esmarch's chloroform 
inhaler. — Hare. 



96 A TEXT-BOOK OF GYNECOLOGY 

to believe that these two instruments should always be in their pocket, 
and should be frequently employed. As a matter of fact, they are very 
rarely, if ever, needed, and the proper manipulation of the head and 
jaw, and grasping the tip of the tongue with the fingers which have 
been covered with a towel, are quite sufficient to produce the proper 
position of this organ. 

There is a common error in the method of manipulating the head 
and jaw in respiratory accidents under anaesthetics. Under such cir- 
cumstances it is the custom to allow the patient's head to fall backward, 
so that the muscles in the anterior portion of the neck are in a condition 
of great extension, and it is thought that by maintaining this posture 
the glottis is widely opened so that air can readily pass in and out of the 
lungs. It is true that this position of the head does widely open the 
glottis, but at the same time it drops the soft palate down upon the dor- 
sum of the tongue in such a way that the patient is required to take all 
the air that he needs through his nasal chambers. These upper air- 
passages are nearly always obstructed by mucus, which has been 
brought out as a result of the local irritation produced by the anaes- 
thetic vapour. In addition, the nasal passages of many patients are 
partially or totally occluded by overgrowth of the mucous membrane 
covering the turbinated bones or by the presence of polypi, so that if 
any of these causes of obstruction are present it is most difficult for the 
patient to get air. If, on the other hand, the anaesthetizer, standing 
at the patient's head in his usual position, places a hand upon each 
side of the head and jaw in such a way that the palm of the hand 
covers each ear and the tip of the middle finger rests under the angle 
of the jaw, and then draws the head toward him, stretching the neck of 
the patient, and at the same time carries the head forward instead of 
backward, the result is that the glottis is quite as widely opened as 
when the head is extended upon the neck and carried backward, with 
the additional advantage that the soft palate is not strapped over the 
dorsum of the tongue, and the patient can, therefore, obtain air both 
through his mouth and nasal chambers. The attitude of the head 
under these circumstances in relation to the rest of the body, save for 
the fact that the patient is prone rather than erect, is that which is 
taken by the athlete when running. Surely no runner desiring to fill 
his lungs with air would tip his head far back with his chin pointed 
upward, but, on the other hand, would project his head' forward in such 
a way as to make his upper passages as patulous as possible. 

Anaesthetic Mixtures. — There are three anaesthetic mixtures to 
which reference should be made before leaving this subject. One of 
these is the so-called A.-C.-E. mixture, which contains alcohol, chloro- 
form, and ether, this combination being made with the idea of securing 
the anaesthetic effect by three drugs; and of combating by the alcohol 
and ether any tendency to cardiac depression produced by the chloro- 
form. Theoretically this mixture has something to recommend it, but 
practically the rapidity of vaporization of these three drugs is so dif- 



ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 97 

ferent that the patient will get first one anaesthetic and then the other, 
and finally the alcohol, so that in reality he does not pass under the 
influence of all three at once. It can not be urged that there are serious 
objections to this mixture, but, on the other hand, there are no material 
advantages in it. The same objection holds against the C.-E. mixture, 
which contains chloroform and ether alone. 

The last anaesthetic mixture which need be mentioned is Schleiclr's, 
which is made according to three formulas, differing, not in ingredients, 
but in the quantity of each ingredient, and which consists in a mixture 
of ether, chloroform, and petroleum ether. It is claimed by Schleich 
that the petroleum ether has no deleterious effects. He believes that 
the effect of chloroform and sulphuric ether, together with the addition 
of petroleum ether, prevents the disagreeable effects which are met with 
when chloroform or ether is given alone. While this mixture on its 
first appearance received considerable attention, increasing clinical ex- 
perience has not been favourable to its employment, and it is speed- 
ily dropping out of use even in the hands of those who first considered 
it of great value. 

Central Anaesthesia by Cocaine. — In 1885 spinal anaesthesia was 
practised by J. Leonard Corning, of New York. Turner utilizes it in 
the following way: A 2-per-cent solution of cocaine is sterilized by 
heating at 80° C, the sterilization being repeated each day for three 
consecutive days. This solution is thrown into the arachnoid space of 
the spinal cord by means of a sterilized hypodermic syringe with a long 
and heavy needle. To administer the injection a line is drawn from 
the crest of one ilium to the other. The forefinger of the left hand is 
placed on the spine of the vertebra immediately above the line just 
indicated. The detached needle of the hypodermic syringe is now 
inserted to the right and a little above the tip of the left forefinger, 
being pushed well into the spinal canal. The escape of the arachnoid 
fluid will indicate that the needle has entered the canal. The loaded 
barrel of the syringe is now attached to the needle through which the 
solution of cocaine is discharged slowly and without force. From 1.5 
to 2 cubic centimetres of the fluid are used, the dose depending some- 
what upon the size of the patient. Anesthesia from the diaphragm to 
the toes will develop in from ten to twelve minutes; and the insensibil- 
ity thus induced will last from one to three hours. The cardiac dis- 
turbance induced by this form of anesthesia is less than that from 
either ether or chloroform. No fatalities have been accredited to it. 
A. Palmer Dudley and other American surgeons have utilized this form 
of central anaesthesia with success in hysterectomy and other equally 
severe operations. It is especially eligible in kidney complications. 

General Anaesthesia by Alcohol. — It is practicable to bring patients 
into a condition of surgical anesthesia by the administration of alco- 
hol. J. M. Matthews, of Louisville, frequently operates painlessly for 
hemorrhoids and other rectal conditions in patients who are thus 
" dead drunk." The alcohol should be given in doses of an ounce 



98 A TEXT-BOOK OF GYNECOLOGY 

every few minutes until alcoholic coma is induced. It is an eligible ex- 
pedient in alcoholic habitues, but is liable to induce an aggravating 
acute gastritis with attendant vomiting in patients who are not 
drinkers. 

General Anaesthesia by Hypnosis. — The researches of Charcot, and 
later of the Medical School of Nancy, have established the possibil- 
ity of entirely destroying physical sensibility by suggestion. Reed 
has operated for the repair of lacerated perineum, and for pelvic abscess 
by vaginal drainage, in patients who had been rendered unconscious 
by hypnotic anaesthesia. This, however, is not to be looked upon 
as an agent or influence of general utility, for the reason that women 
are not all subjective, and for the further reason that, notwith- 
standing there are no reflex manifestations of pain, nor any memory 
of the operation, it still seems that the impression registered upon the 
secondary or induced consciousness provokes shock to a degree that 
is not realized under general anaesthesia as ordinarily practised. The 
subject is one pregnant with great possibilities, and should be subjected 
to more critical study than has yet been accorded it by the English- 
speaking medical profession. 

Local Anaesthesia. — It is sometimes desirable and even imperative 
to avoid the administration of general anaesthetics. Pain may be re- 
lieved under such circumstances by benumbing the parts with cold or 
with ether, or by using a subcutaneous injection of a 2-per-cent 
solution of cocaine. The latter remedy, however, should not be looked 
upon as innocuous, so far as its constitutional effects are concerned, 
serious cardiac and respiratory complications having ensued upon the 
administration of but a small quantity. 



CHAPTEB XII 

ABDOMINAL SECTION 

Terminology — Preliminary treatment of the patient — The evil of hypercatharsis — 
Examination of the urine — Instruments — Preparation of the field of operation 
— Location of the incision — Direction and varieties of the incision: Vertical 
median, transverse umbilical, transverse suprapubic, oblique ventral, inguinal, 
oblique subcostal, lumbo-iliac, lumbo-costal — General observations on making 
the incision — Closure — Immediate and complete by laminated suture — Where 
drainage is necessary by suture en masse — Drainage. 

Theee has been much discussion of the various terms which, from 
time to time, have been coined to designate the operation whereby the 
abdominal cavity is opened and its viscera made accessible for surgical 
purposes. Blancard, of Middleburg, Zealand, published a work nearly 
two hundred years ago in which he employed the word " gastrotomia " 
to designate " the cutting open of the abdomen and womb, as in sectio 
Ccesarea" The word comes from two Greek terms — namely, yaarrip, 
meaning belly or stomach, and TOfirj, meaning incision. The first 
of these terms was formerly employed in its ordinary and vulgar 
sense of belly. Since operations upon the stomach proper have come 
into vogue, the term has been narrowed in its significance, and is 
commonly used exclusively to designate the operation of making 
fistulas into that organ. 

Laparotomy (derived from Xairdpa, the flanks, and to/x->J [re/xvetv, to 
cut]; French, laparvtomie; German, Laparotomie) was, perhaps, the 
next coinage, and had, originally, a meaning that was entirely consist- 
ent with its purpose. It was employed early in the nineteenth century 
to designate the operations in the inguinal regions, as, for instance, for 
hernia and colotomy. In later years, however, with the advent of 
what has since become known as abdominal surgery, " laparotomy " 
was made to mean all operations upon the abdominal wall. This was 
such a manifest misapplication of the original meaning of the term 
that the profession has largely abandoned its use. The first revolt 
was emphasized by Lawson Tait, who employed in its stead the 
expression " abdominal section." This term, in turn, has occasioned 
considerable discussion. Greig Smith says that it is, perhaps, " most 
objectionable of all; an abdominal section," he adds, " is made 

L.ofC. " 



100 A TEXT-BOOK OF GYNECOLOGY 

on a frozen cadaver with, a saw for anatomical purposes; it is not 
easy to understand how an evil chance led to the name being 
given to an incision made through part of the abdominal wall for sur- 
gical purposes/' 

This criticism must be recognised as of doubtful accuracy. The 
word " section " is derived from the Latin sedio, meaning simply " to 
cut." A statement that " section " must imply amputation or an abso- 
lute severance of one part from the other, is, therefore, an unjustifiable 
stricture. The fact remains that, by convention at least, it has come 
to be synonymous with incision. This has been verified through gen- 
erations, and for that matter centuries, in the term Csesarean section. 
Latterly we hear of perineal section, sagittal section, and many other 
equally legitimate applications of the word. The word celiotomy — ■ 
from the Greek /cotAia, the belly, and Ttfxvecv, to cut, and correspond- 
ing in significance with the French cceliotomie, the German hoilotomie 
and oauchsclinitt — does not materially help the situation. The word cce- 
liotomy was brought to the attention of the profession by the late 
Dr. E. P. Harris, of Philadelphia, although Dr. F. P. Foster, writing 
on the subject, says " this term seems to have been introduced 
by Davies-Colley." " Some good people/' continues Foster, " write 
it celiotomy; many consider it more expressive than laparotomy, but 
with its adoption has sprung up the curious term ' abdominal cce- 
liotomy,' an abdominal opening of the abdomen, as distinguished 
from vagina] cceliotomy. The term abdominal section answers every 
purpose, and seems to me preferable to both cceliotomy and lapa- 
rotomy." 

The Preliminary Treatment of the Patient. — In the absence of an 
emergency, such as hemorrhage, acute sepsis, or strangulation, time 
should be taken to prepare the patient's system for the operation. 
This should be done b}^ giving particular attention to the state of the 
secretions. Most patients, particularly those of the more chronic class, 
are constipated, and their systems are, as a consequence, laden with tox- 
ines from the hyperabsorption constantly going on from the alimen- 
tary canal. The condition is all the more serious because of the de- 
fective peristalsis which is liable to be still further weakened, if not 
entirely arrested, by the influence of the operation upon the sympa- 
thetic nervous system. It is highly important, therefore, for these 
two reasons, if for no other, that the bowels should be not only un- 
loaded, but brought to an approximately normal standard of activity. 
This is best done by giving the patient a small dose (one sixtieth of a 
grain) of strychnine with salol (three grains) three times daily associ- 
ated with a persistent course of salines. For the latter purpose 
the magnesium sulphate, the sodium sulphate, or the sodium phos- 
phate, may be employed, either in the form of some of the natural 
mineral waters, or by dissolving some of the salt in plain water. More 
important, perhaps, than the selection of the remedy is the manner of 
its administration. The best results are obtained by giving drachm 



ABDOMINAL SECTION 



101 



doses, beginning, not before, but after a meal. If the chosen remedy 
is continued in this way during twenty-four hours and no laxative 
effect is realized, it may be well to unload the bowels of their now 
softened contents by administering one full dose of the medicament, 
given this time on an empty stomach. The saline should not be dis- 
continued so soon as the bowels have been evacuated, although a little 
time should be given for the previously secured laxative effect to 
subside. The saline should then be resumed in half doses, given an 
hour or two after each meal. In this way it becomes mixed with the 
ingesta, and, by stimulating both secretion and peristalsis, prevents a 
return of the constipation. A constipation of long standing may 
thus frequently be broken up in the course of a week, often with 
permanent results. 

The Evil of Hy- 
percatharsis. — It is 
highly important to 
urge a word of cau- 
tion against the 
prevalent habit of 
purging patients ex- 
cessively before op- 
erations. It is not 
unusual for patients 
to be forced to have 
a dozen or more de- 
jections during the 
twelve or twenty- 
four hours before 
undergoing the or- 
deal of an abdominal 
section, and during 
this time they are 
kept upon a re- 
duced diet, and often 
during the final 
twelve or fifteen 
hours are given 
nothing at all to 
eat. It should be 
borne in mind that 
such hypercatharsis 
(a) weakens the pa- 
tient, (b) still further weakens peristalsis, (c) aggravates post-operative 
thirst, and (d), by draining the circulation, stimulates all of the absorb- 
ent functions, and thus lays the foundation for systemic sepsis in 
the presence of unavoidable local infection. The practice is wholly 
wrong and should be abandoned. 




Fig. 31.— "Fenton B. Turck covers the abdominal wall with 
a sheet of rubber dam." — Eeed (page 102). 



102 



A TEXT-BOOK OF GYNECOLOGY 



Examination of the urine is very important, as is the correction, 
by judicious medication, of any error that may be found in that secre- 
tion. The condition of the skin should equally be the object of careful 
investigation and treatment. This latter precaution is of greater impor- 
tance than is generally recognised. It is only necessary to mention that 
failure of the urinary function, as the result of the action of the anaes- 
thetic on the kidneys, is one of the most frequent fatal complications 
following visceral operations; and that in the presence of such a com- 
plication the chief hope of the patient lies in the compensatory activity 
of the sweat glands. It is highly important, therefore, that they be 
put in a state of normal activity before the operation. Baths, if 
necessary, with dry heat or steam and followed by friction, continued 
during several days, generally constitute all the treatment that is 
required. 

The digestive function should be brought to as high a state of effi- 
ciency as possible. 

Penton B. Turck covers the abdominal wall with a sheet of rubber 
dam (see Fig. 31). This is stretched taut, and, being translucent, does 
not obscure the underlying integument; the incision is made directly 




Fig. 32. — " The cut edges of the rubber dam are brought forward and tucked into the 

wound." — Eeed. 



through the dam just as if it were a part of the skin. After the inci- 
sion is completed, the cut edges of the rubber dam are drawn for- 
ward and are tucked into the wound, covering its margins and being 
retained by a clothes-pin arrangement, as shown in the drawing (Fig. 
32). The rubber dam is further utilized by Turck in preventing infec- 
tion of the peritoneal cavity by drawing a loop of intestine to be oper- 
ated upon through a small hole in the rubber sheet. 



ABDOMINAL SECTION 



103 



Instruments for an Abdominal Section 



Aspirator. 

Cautery (Paquelin). 

Forceps : 

Long dressing 1 

Long hemostatic 6 

Medium hemostatic 3 

Small hemostatic 3 

Bullet 1 

Rat-tooth 2 

Needles, curved : 

Very large (No. 1) 1 

Large (No. 4) 2 

Intermediate (No. 3) 2 

Small (No. 2) 2 

Intestinal (No. 1) 2 

Transfixion, right curved 1 



Needles, straight 2 

Needle holder 1 

Retractors : 

Large 2 pairs 

Next size smaller . . 2 " 

Scalpels 2 

Scissors : 

Long 1 pair 

Short 1 " 

Sound, uterine 1 

Speculum, Situs's small 1 

Sponge holders 4 

Tenacula : 

Straight 1 

Curved 1 



Additional Instruments for Ovarian Cysts 
Trocars, large and small. Two Nelaton forceps. Rubber tubing. 

Additional Instruments for Extra-uterine Pregnancy, Hysteromyomectomy, or 
Supravaginal Hysterectomy, and Vaginal or Infra vaginal Hysterectomy 

One dozen pairs of long hemostatic forceps. 
Two Museux's forceps for seizing tumours. 

Glassware 

Catheters 2 

Drainage tubes, assorted sizes : 

Straight 3 

Curved 3 

Flask, sterilized, to receive fluid (contents of cysts, etc.) for examination 1 

Nozzles (for irrigation) 2 



Preparation of the Field of Operation. — (See Preventive Treatment 
of Sepsis.) 

Location of the Incision. — The abdominal incision is generally- 
located in the median line for the reason that this particular situation 
enables the operator to more freely handle the parts of the abdominal 
and pelvic cavities. This rule is adopted more particularly in the old 
operation of Cesarean section, and in the more recent procedure of ova- 
riotomy. In the former instance it was manifestly to the convenience of 
the operator to get down directly upon the uterus. In the second class 
of cases it vras more desirable because it enabled the surgeon to deal 
with either side of the pelvis with equal facility; latterly, however, the 
principle has gained recognition that the incision should be made 
directly over the organ or structure which is to be dealt with. 



104 



A TEXT-BOOK OP GYNECOLOGY 



The question of hernia resulting from the unsatisfactory restora- 
tion of the incised abdominal wall is also an important consideration in 
determining the location and character of the incision. It is generally 
supposed that the cut in the median line directly through the linea alba 
is best calculated to avoid unpleasant consequences. Of the incision 
in this location, it may be said that it is the easiest to make, and, by 
avoiding blood vessels, is least complicated with hemorrhage. It is 
closed with great facility, and the union which ensues is generally very 
satisfactory. If infection should occur, however, the approximation 
of the structures, however accurately made, may be destroyed, and the 
margin of the wound thus become retracted. This is of very serious 
import when the incision is a little to one side or the other of the 
median line, and when the separation involves the margins of the 
fasciae. This — i. e., separation of the fascia — is the underlying condi- 
tion of post-operative ventral hernia; to avoid this accident many oper- 
ators prefer to invade the abdominal cavity a little to one side or the 
other of the median line, some preferring to go as far to one side as the 

outer margin of the 
rectus muscle; some 
preferring to go di- 
rectly through the 
rectus ; while still 
others open the 
sheath of that muscle 
near the median line, 
pushing the muscle 
itself to one side and 
continuing the inci- 
sion through the 
middle of the under- 
lying layer of sheath 
and fascia. In this 
way it is contended 
that should one layer 
separate, the other 
layer, directly super- 
imposed, will exercise 
a greater retentive 
power, and thus pre- 
vent the development 
of hernia. 

This principle is 

one which is capable 

of adoption in many 

operations. It should be observed, especially in fat subjects, where, in 

consequence of the disuse of the abdominal muscles, or of the stretching 

incident to distention by fat, or from the pressure due to the presence 




Fig. 33. — " The incision may be made in that locality which 
will afford the greatest facility in dealing with the under- 
lying internal conditions." — Keed (page 105). 



ABDOMINAL SECTION 105 

of deposits of adipose tissue, the structures of the abdominal wall are 
materially weakened. It should be remembered that an incision may- 
be made at any point in the abdominal wall, and that there are no 
blood vessels contained therein the hemorrhage from which is not 
readily controllable. As a rule, therefore, the incision may be made 
in that locality which will afford the surgeon the greatest facility in 
dealing with the underlying internal conditions (Fig. 33). 

Direction and Varieties of Incision. — While the foregoing is true, it 
is also true that there are distinct advantages to be gained by definitely 
and accurately arranging the direction of the incision into and through 
the abdominal wall. It is also true that, consistently with the object in 
view, the incision is best made (a) coincidently with the cutaneous 
folds, and (b) coincidently with the muscular fibres and fascial strice. 
This principle was enunciated by Kocher {Operative Surgery, New 
York, 1894), who definitely outlines the incisions to be made for vari- 
ous purposes, some of which come properly within the range of a work 
on gynecology, and are given herewith. The line of the median ab- 
dominal incision is, as already stated, the one most commonly employed. 
While it is made transversely to the normal cutaneous folds it is coin- 
cident with the recti muscles, a fact that conduces largely to the easy 
and permanent approximation of the deeper structures. The results, so 
far as the skin is concerned, are, however, often somewhat unfortu- 
nate, if from no other than an aesthetic point of view. The retraction 
of the skin that frequently ensues, notwithstanding the most careful 
approximation of the cutaneous margins, frequently results in post- 
operative widening of the cicatricial area. Frequently under this in- 
fluence the scar tissue undergoes what is spoken of as a keloid change. 
When, therefore, the cutaneous incision can be made transversely, 
the underlying layers being divided in amy direction to suit the oper- 
ator, but preferably in the direction of their respective strice, the result 
is always more satisfactory. There is nothing more striking than the 
difference between a scar made transversely to, and one coincidently 
with the cutaneous folds, the latter becoming practically imperceptible 
after a very few weeks, Avhile the former shows a constant tendency to 
increase in size and to diminish in retentive power. 

The Vertical Median Incision. — The incision E (Fig. 33) may be 
called the low vertical median incision, while that designated G 
(Fig. 33) is the high vertical median incision. The latter should be 
employed in operations upon the stomach, and in other operations in 
which it is desirable to reach the organs lying in the upper part of 
either of the upper quadrants of the abdominal cavity. A vertical in- 
cision (H, Fig. 33) is sometimes made in the left upper quadrant for 
operations upon the spleen. The incision in the median abdominal 
line is the best in all cases in which it is necessary to deal with both 
sides of the pelvis, or in those cases in which it may be uncertain as to 
which side of the pelvis may be the ultimate seat of operation. The 
median line is, as a rule, the safer locus for a general exploratory in- 



106 A TEXT-BOOK OF GYNECOLOGY 

cision. It should always be employed in the presence of surgical condi- 
tions lying immediately beneath it. 

The Transverse Umbilical Incision. — This incision is made trans- 
versely at the umbilicus, and may be employed in dealing with prac- 
tically all conditions developing in that locality. It is the ideal in- 
cision in the management of umbilical hernia. As a rule, a post- 
operative ventral hernia, occurring in this locality, or, for that matter, 
at any other point above or below the umbilicus, may be safely and 
desirably approached through a transverse incision, while the her- 
nia itself should be approximated in a transverse rather than a longi- 
tudinal line. This line of incision is of especial importance in fat 
people. These patients, lying upon their backs, exercise all of the 
gravity which is derived from the heavy and mobile abdominal walls in 
a spontaneous tendency to retract from the longitudinal median line, 
while their equally natural tendency is to hold a transverse approxi- 
mation in continued apposition. 

The Transverse Suprapubic Incision (C, Fig. 33). — This incision 
should be made transversely to the median line, immediately above 
the pubes, in all operations in which it is desirable to approach the 
bladder from the outside. This occurs with frequency in gynecological 
practice. 

The Oblique Ventral Incision (A, Fig. 33). — The oblique ventral in- 
cision should be employed in dealing with the common iliac artery, as 
sometimes becomes necessary in gynecological practice; it may be used 
on the right side in dealing with the suppurations about the head of the 
colon and in appendicitis, or in surgical conditions pertaining to the 
pelvic bones on that side. On the left side it is the avenue of approach 
to the sigmoid flexure as well as to the common iliac artery. 

The Inguinal Incision (B, D, Fig. 33). — The inguinal incision may 
be made either above or below, but coincidently with, the line of Pou- 
part's ligament. In the former position it may be employed in inguinal 
hernia or to reach conditions beneath the broad ligament in order that 
they may be dealt with without communicating with the peritoneal 
cavity. Suppuration in this locality may be evacuated and drained by 
an incision along this line, while retroperitoneal myotomy, or, for that 
matter, intraligamentary cysts, may be approached by this incision, 
after their true character has once been determined by the incision in 
the median line. 

This incision is sometimes made below Poupart's ligament in deal- 
ing with femoral hernia and with conditions connected with the fem- 
oral artery. 

The Oblique Subcostal Incision (F, Fig. 33). — The oblique subcostal 
incision should be made from a half to three quarters of an inch be- 
neath the costal margins, extending from the outer margin of the rectus 
muscles to as far around the side as may be necessary. This operation 
is sometimes desirable in making explorations for the kidney — a pro- 
cedure which comes within the purview of this work; it is usually em- 



ABDOMINAL SECTION 



107 



ployed, however, for operations upon the gall bladder, which are not 
considered in this volume. 

The Lnmbo-iliac Incision. — This incision begins near the last costo- 
vertebral articulation, extending downward and forward in the direc- 
tion of the crest of the ilium. It may be employed in the case of ne- 
phrectomy, or for the complete removal of the ureter. 

The Lumbocostal Incision. — This incision is made from a point 
one to two inches to the side of the posterior median line, and carried 
obliquely downward, forward, and upward below the costal margin. 
It is employed for operations upon the kidney. 

General Observations on making the Incision. — Wherever the inci- 
sion may be located it should be made deliberately, all attempts at 
haste being avoided. The layers should be incised one by one. Bleed- 
ing points will, of course, be encountered, some localities and some 
patients being more vascular than others. The blood should be speed- 
ily wiped away by means of a bit of dry sterilized gauze, so that the 
structures may be kept clearly in view. The gauze thus used should be 
immediately thrown away. Much time is often lost in needless atten- 
tion to unimportant bleeding. As a rule, that bleeding which is merely 
capillary or venous may be left to itself, while a pulsating jet should be 
at once controlled by means of a hemostatic forceps. This should 
not be hastily applied, and should always be adjusted with care and 
precision. Many careless operators and assistants simply take a large 




Fig. 34.- 



u-esenting structure should be picked up by two hemostatic forceps.' 1 — Keed. 



bite of tissue somewhere in the neighbourhood of the bleeding point, 
with the object, of course, of controlling the hemorrhage. The pres- 
sure thus imposed upon the tissue, particularly the adipose tissue, which 
is found in such abundance in the abdominal wall, is liable to induce 



108 



A TEXT-BOOK OF GYNECOLOGY 



necrosis, and thus interfere with primary union. A few seconds of time 
should be taken to isolate more or less definitely the bleeding point, 
which should then be picked up accurately by the point of the hemo- 
static forceps. 

As soon as the deep fascia or the subperitoneal fat is reached, the 
presenting structure should be picked up by two hemostatic forceps (Fig. 

34), which should be re- 
applied as often as may 
be necessary to hold the 
peritoneum away from 
the underlying viscera. 
The moment the peri- 
toneum is nicked the 
air rushes in and the in- 
testines fall away from 
the abdominal wall. 
Failure to observe this 
precaution sometimes re- 
sults in the totally un- 
necessary wounding of 
the intestines or other 
structures within the ab- 
dominal cavity. The 
peritoneum should be 
carefully incised by 
means of either scissors 
or a knife, coincidently 
and coextensively with 
the upper part of the in- 
cision (Fig. 35). 

As soon as the peri- 
toneum is opened, care 
should be taken to per- 
manently arrest all hem- 
orrhage in the abdominal 
incision and to remove 
the forceps. In the course 
of an operation it may be, 
and frequently is, neces- 
sary to enlarge the inci- 
sion; in doing so great care should be exercised to make the additional 
opening directly in line with the previous one, and to observe the 
same precautions in dealing with the incidental hemorrhage. It is 
better to employ a knife for this purpose rather than the scissors, which 
are generally so convenient, so expedient, and so generally utilized by 
the hurried surgeon. The scissors are objectionable, because in the act 
of cutting they produce a certain amount of cell destruction, which is 




Fig. 35.—" The peritoneum should be carefully incised 
. . . coincidently and coextensively with the upper 
part of the incision." — Eeed. 



ABDOMINAL SECTION 



109 



obviated by the keener edge of the knife. The incision having been 
made as large as necessary, the operation, whatever it may he, is car- 
ried to completion. 

The Closure of an Abdominal Incision. — There are various methods 
of closing the abdominal incision. The question of interrupted or con- 
tinuous suture, the question of suture material, and the question of 
sealing or not sealing the wound, are all to be considered: this is bet- 
ter done with reference to the necessity or not of maintaining drainage. 

The Immediate and Complete Closure of an Abdominal Incision. — 
When the operation has been successfully concluded, when the field 
of operation has remained free from infection, when hemostasis has 
been secured, and when there are no remaining doubts as to the safety 
of the internal conditions, the abdominal wound may be closed com- 
pletely and at once by one of the following methods: 

Closure by the Laminated Suture. — The ideal method of closure is 
by the approximation, edge to edge, of like structures; thus the peri- 
toneum to the peritoneum, the tranversalis fascia to the transversalis 
fascia, the superficial fascia to the superficial fascia, and the integu- 
ment to the integument, should be successively approximated. This 
may be done either by continuous or interrupted suture or chromicized 
or formalinized catgut. The kangaroo tendon and other tendinous 
materials have a certain vogue for this purpose, but they are not essen- 
tial to success. If a continuous suture is applied in each layer it ought 
to be supplemented by a number of interrupted sutures in the fascial 
layers, as these structures are more prone to retract than are the others. 
and they are likewise 
the chief retentive tis- 
sues of the abdominal 
wall. It is not safe, 
therefore, to trust their 
approximation to a sin- 
gle continuous suture. 
The application of the 
sutures to the various 
layers is largely facili- 
tated by drawing up. by 
two small volsella for- 
ceps, each consecutive 
layer into the field of 
operation (Fig. 36). 
Volsella forceps are 
vastly better adapted to 
this purpose than are 
those used for hemo- 
stasis. because they exercise no pressure, and consequently induce no 
cell destruction. The skin should be closed by means of intercuta- 
neous suture, but before starting this suture the end should be fastened 




Fig. 36. — " The application of the sutures to the various 
layers is largely facilitated by drawing up. by small 
volsella forceps, each consecutive layer into the Held 
of operation." — Reed. 



110 



A TEXT-BOOK OF GYNECOLOGY 



in such a way as to place the knot deep in the subcutaneous fat (Fig. 37) 
in order that its absorption may be insured. This is done by passing 
the needle through the subcutaneous fat from beneath, carrying it 
across to the other margin of the wound, and downward through the 
fat, bringing it out at a point corresponding to the original insertion 

on the other side. The suture is 
now tied and the short end cut 
close. In order to secure perfect 
approximation at the end of the 
wound, the first intercutaneous 
suture is passed toward the end 
from which the suture starts 
(Fig. 38). The remaining su- 
tures are passed in the other 





Fig. 37. — " The end should be fastened in 
such a way as to place the knot deep in 
the subcutaneous fat." — Reed. 



Fig. 38. — " The first intercutaneous su- 
ture is passed toward the end from 
which the suture starts." — Reed. 



direction, the margins of the skin being carefully drawn together 
(Fig. 39). There are connected with this last manoeuvre certain dan- 
gers, for instance, the unsuccessful application of the sutures, leaving a 
gaping point to serve as an infection atrium; or, on the other hand, if 
too tightly drawn after they have been inserted, the pressure itself 
may be destructive of the integument and may result in a necrosis, 
which is disastrous to primary union. After having applied the inter- 
cutaneous suture there may be some retraction of the subcutaneous fat, 
a condition which is easily remedied (Fig. 40). This is done by taking 
a long curved needle, inserting it an inch or less back from the line of 
incision, crossing the incision itself, and bringing the needle out at a 
corresponding distance on the other side. The needle is then rein- 



ABDOMINAL SECTION 



111 



serted through the aperture of exit, and is carried in a more or less 
oblique way back to the opposite side, where it is brought out half an 
inch distant from the point of original 
insertion (Fig. 41). The suture thus 
buried approximates the underlying 
fat, and in an important degree forti- 
fies the cutaneous approximation. It 
is returned in the same manner until 
the whole line of incision has been 
brought under the influence of the 
suture. It is then tied under the skin 
by inserting the needle and working 
its point two or three times around 
the strand of catgut immediately un- 
der the skin. The needle is then 
brought out on the other side and the 
catgut excised under traction close to 
the skin. The end immediately re- 
tracts and the whole operation will 
have been completed entirely beneath 
the integument. 

It is well in the majority of 
cases to seal the wound by adjusting 
over it a little sterilized gauze fixed 
to the surface by means of collodion, 
but the impossibility of sterilizing col- 
lodion should prevent its application 
directly to the margins of the wound. 
After the abdomen is well cleansed 
and dried it should be tightly bound 
with a cloth bandage. That in use 
at the Cincinnati Hospital is probably 

more advantageous than others, it being held firmly in place by two 
flaplike elongations of the back part which are brought up between the 

thighs and fastened to 
the front of the bandage 
(Fig. 42). 

Closure where Drain- 
age is Necessary. — In 
many operations it is not 
possible to secure com- 
plete hemostasis or that 
degree of asepsis com- 
patible with safety, or to 
control other surgical conditions to a degree that will justify the com- 
plete closure of the abdominal incision. Drainage must, therefore, be 
employed and an orifice of exit must be provided. This is sometimes 




Fig. 39. — " The remaining sutures are 
passed in the other direction, the 
margins of the skin being carefully 
drawn together." — Eeed (page 110). 




Fig. 40. — " After having applied the intercutaneous su- 
ture there may be some retraction of the subcutaneous 
fat, a condition which is easily remedied." — Eeed 
(page 110). 



112 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 41. — " The needle is reinserted through the aperture of 
exit, and is carried in a more or less oblique way back to 
the opposite side." — Reed (page 111). 



done by making an 
opening in the cul-de- 
sac of Douglas and 
carrying a self -retain- 
ing tube out through 
the vagina. In other 
instances this will not 
suffice. Many opera- 
tors still cling to the 
old glass tube and 
pump, while in certain 
other instances it is 
necessary to pack the 
field of operation with 
gauze and bring one end of it out through the incision. The neces- 
sity for the latter expedient is sometimes so great as to make it neces- 
sary to leave open the entire wound. Under any of these circumstances 
it is necessary to leave a part or all of the incision open. In such 
cases it is not better to 
employ the buried animal 
suture, for the reason 
that the drainage, how- 
ever established or how- 
ever maintained, is neces- 
sarily a fruitful source of 
infection; and infection 
once communicated to 
the continuous laminated 
animal suture is liable to 
invade all of the struc- 
tures that may be approx- 
imated by it. 

Closure by the Suture 
En Masse. — To close the 
wound when drainage is 
required, the suture en 
masse should be em- 
ployed. This may con- 
sist of silk, silver wire 
or silkworm gut — the lat- 
ter on all accounts being 
preferable. The material, 
having been sterilized, of 
course, may be inserted 
from the skin to the peri- 
toneum, carried across 
from peritoneum to peri- 




Fig. 42. — " The bandage in use at the Cincinnati Hos- 
pital is probably more advantageous than others."— 
Reed (page 111). 



ABDOMINAL SECTION 



113 



s 



Fig. 43, 



-The needle < 
Holmes 



/ised \ 
-Reed. 



Dr. J. B. S. 




toneum and through from peritoneum to skin. For this purpose many 
operators prefer a straight needle, others a curved one; the most satis- 
factory one which the writer has encountered has been devised by Dr. 
J. B. S. Holmes, of Atlanta, Ga. It is a round needle bent at an 
angle near the point, which has a bayonet finish (Fig. 43). The needle 
in passing through the ab- 
dominal wall should be 
made to define an arc of a 
circle, so that when drawn 
together the intermediate 
structures will be brought 

well forward and forced into approximation (Fig. 11). In a few in- 
stances it may be found necessary to bring the traction to bear more 
specifically upon the margins of the fascia. This is accomplished by 
a figure-of-eight arrangement, effected as follows: The needle is in- 
.serted through the skin and superficial fascia, brought out into the 

margin of the wound, 
inserted into the oppo- 
site side just below the 
superficial fascia, car- 
ried through the peri- 
toneum, crossed over, 
inserted through the 
peritoneum and brought 
out just beneath the su- 
perficial fascia, crossed 
over to the other side, 
inserted through the superficial fascia, and brought out through the 
skin. The resulting suture is a complete figure eight, which forces 
into approximation the fascia which, under many circumstances, is 
prone to retract to a degree calculated to defeat the union (Fig. 45). 
The sutures having been inserted, the ends are gathered together 
upon either side and 
the entire abdomi- 
nal wall is drawn 
away from the in- 
testines, the perito- 
neal margins being 
forced together by 
properly directed 
traction upon all 
the sutures. This 

having been done, the ends of the sutures may be permitted to lie freely 
while the operator ties each one seriatim. If the material is silkworm 
gut the preliminary loop of the knot should be accomplished by three 
turns, and should be drawn together with just sufficient force to effect 
the approximation of the tissues, but without force enough to interfere 



Fig. 44. — " The needle, in passing through the abdominal 
wall, should be made to define the arc of a circle." — 
Eeed. 




Fig. 45. 



-"The resulting suture is a complete figure of 
eight." — Eeed. 



114 A TEXT-BOOK OF GYNECOLOGY 

with the local nutrition of the parts. A suture that blanches the skin, 
under it is tied too tightly. This can not always be avoided, because 
the post-operative engorgement of the parts sometimes increases pres- 
sure to a dangerous degree. If the suture has been secured as already 
indicated — namely, by an extra whirl in the preliminary loop — it is 
totally unnecessary to apply the usual second loop for fixation. If, 
then, the tension should subsequently appear to be too great, the suture 
can be loosened. An extra suture may be inserted to secure approxima- 
tion at the point occupied for drainage. If applied, this suture should 
be left loose until after the drainage is concluded. It may be stated, as 
a rule, however, that this expedient is one of doubtful utility, and is 
not infrequently fraught with some danger. It is better, as a rule,, 
to leave that section of the wound which has been employed for drain- 
age open for spontaneous closure. 

Drainage. — Drainage was at one time considered more essential to 
success in abdominal surgery than it is at the present day. At the time 
when surgeons were less sure of hemostasis it was a safeguard in detect- 
ing internal hemorrhage, and it should yet be employed in all cases in. 
which the operator has any doubt about having controlled the bleed- 
ing. In former times, when the toilet of the peritoneum was less care- 
fully made than at present, drainage was essential for the escape of 
pus, which continued to form until limited by the self-extermination 
of its micro-organisms. Drainage may be practised by leaving in the 
abdominal wound a glass tube extending to the bottom of the pelvis. 
Through this tube the accumulated fluids are sucked with an appa- 
ratus consisting of either a syringe or a rubber bulb with a glass barrel 
attached to a bit of rubber tubing. The manipulation requires great 
care to prevent infection, the liability to which by this means consti- 
tutes one of the chief objections to drainage as a routine measure. In 
many abdominal operations in which it is desirable to promote the 
escape of fluid, drainage is effected by making an opening in the floor 
of the cul-de-sac of Douglas and inserting through that into the vagina 
either a small rope of gauze, or preferably a T-drainage tube. These 
are made of rubber after the pattern of Martin, but as found in the 
shops are unnecessarily expensive. Just as efficient a drainage tube 
can be made by taking a piece of ordinary quarter-inch drainage- 
tubing, eight inches long, and cutting it off oval at one end. The tube 
is then split for a distance of an inch and a half into two flaps; an eighth 
of an inch below the base of each flap a small hole is cut into each 
side of the tube; through each of these holes the corresponding flap 
is drawn by means of an ordinary hemostatic forceps; the result is the 
formation of a T-tube of great utility (Fig. 46). Delageniere has de- 
vised metal drainage tubes, but their advantages are not obvious. Gauze- 
has been used for drainage purposes, but it speedily becomes filled with 
the secretions, which it fails to conduct out of the cavity; its use, there- 
fore, should be limited to those cases in which the fluid expected to be 
taken out by it is not in excess of the absorbing capacity of the gauze to 



ABDOMINAL SECTION 



115 



be used. J. G. Clark investigated the general question of drainage in 
seventeen hundred abdominal sections at the Johns Hopkins Hos- 
pital (American Journal of Obstetrics. April, 1897). In approaching 
his investigations he proceeded upon the conclusions of Muscatello — 





Fig. 46. — " The result is the formation of a T-tube of great utility."— Reed i page 114). 



viz.: (1) the surface of the peritoneum is equivalent to that of the skin; 
(2) it has an enormous absorbing function, taking up in an hour from 
3 to 8 per cent of the entire body weight; (3) under the influence 
of very toxic or very irritant substances an equal transudation into 
the peritoneal cavity may take place. Clark, from a general study 
of the subject as well as from these investigations, concludes that — 

1. Fluids and solids may pass through the endothelial layer of the 
peritoneum, the fluids in many places, the solid particles only through 
the spaces in the diaphragm. 

2. The minute solid particles are carried into the mediastinal lymph 
vessels and glands, and thence into the blood circulation, by which 
they are distributed to the abdominal organs and lymph glands. 

3. Large quantities of fluids may be absorbed by the peritoneum in 
an astonishingly short time. 

4. The leucocytes are largely the bearers of foreign bodies from the 
peritoneal cavity into the mediastinal lymph glands. 

As the result of the experimental study of infection of the perito- 
neum by Grawitz. it has been shown that — 

1. The introduction of nonpyogenic organisms into the abdom- 
inal cavity, either in small or large quantity, or mixed with formed par- 
ticles, produces no harm. 

2. Great quantities of organisms, which ordinarily produce no dis- 
turbance, may give rise to a general asepsis if the absorptive ability of 
the peritoneum is impaired. 

3. The injection of pyogenic organisms into the peritoneal cavity 
may be quite as harmless as injection of the nonpathogenic varieties. 



116 A TEXT-BOOK OF GYNECOLOGY 

4. The introduction of pus-producing cocci causes a purulent 
peritonitis (a) if the culture fluid is difficult of absorption; (b) if there 
is present irritating material which destroys the tissues of the perito- 
neum, and thus prepares a place for the lodgment of organisms; (c) if 
a wound of the abdominal wall is present which forms a nidus for the 
infectious process. In this latter case purulent peritonitis will cer- 
tainly be produced. 

It was further found that the area drained by a tube speedily be- 
came limited, almost to the circumference of the tube itself; that the 
tube frequently acted mechanically, and thus perpetuated the peritoneal 
exudation; that the serum thrown off by the peritoneum acted as the 
best possible culture medium for germs introduced from without; and, 
finally, that any agents that had any possible effect upon bacteria acted 
as an irritant to the peritoneum, and thus defeated the purpose for 
which they were employed. 



CHAPTER XIII 

THE EXTERNAL ORGANS OF GENERATION IN WOMEN 

Names and definitions — Development — The vulva and its malformations: atresia; 
infantile ; double ; persistent cloaca ; persistent urogenital sinus ; epispadias in 
women; precocious development; individual malformations of the labia, cli- 
toris, and perineum; pseudo -hermaphroditism : (a) masculine, (6) feminine — 
The vagina and its malformations : absence ; atresia ; stenosis ; double or sep- 
tate — The hymen and its malformations : atresia ; double ; absence ; anomalies 
in (a) form, (b) structure, (c) anterior extension. 

The external organs of generation in women consist of the puden- 
dum and vagina. The pudendum embraces the structures known as 
the mons veneris, the labia majora, the labia minora, the clitoris and 
prepuce, the vestibule and fourchette, and the hymen. The word 
" vulva " applies to all of these external structures except the mons 
veneris. For convenience of classification the perineum will be con- 
sidered in this same group. 

Development of the Genital Organs. — The genital organs, whether 
male or female, have their embryologic origin in the Wolffian body, 
Midler's ducts, and the genital glands. From the Wolffian body, or the 
primordial kidney, there appear on the inner portion, and in the fifth 
and sixth months of utero-gestation, the genital glands, which subse- 
quently evolve into either ovaries or testicles. If, however, at the end 
of the third month, when differentiation of sex is manifested, the geni- 
tal glands develop into ovaries, the Wolffian body and canal atrophy, 
almost disappearing, and leave as their only remnant the organ of Ko- 
senmuller in the broad ligament. Midler's duct, however, persists, and 
from it are developed the Fallopian tubes, while the round ligament is 
developed from the yet persisting ligament of the Wolffian body, blend- 
ing, however, with Midler's ducts at the junction of the superior with 
the middle third. The external organs of generation are derived from 
the genital tubercle, which appears at about the sixth week of foetal 
life and reaches its maturity during the succeeding two weeks. After 
the development of the genital folds and at the end of the second 
month there is recognisable on its posterior surface a furrow extending 
in the direction of the cloaca and designated the genital groove. This 
is the beginning of sex development, the subsequent steps of which, 
as outlined by Pozzi, are as follows : " The genital groove does not close 
more in front than behind, and thus the female lacks the clitoridian 

117 



118 A TEXT-BOOK OF GYNECOLOGY 

portion of the urethra; and this canal in the adult opens at a point 
homologous with that where it was found in the foetus of eight weeks — 
a disposition which is found in the male when the proper development 
of the parts has been arrested (hypospadias). The corpus spongiosum 
of the urethra, the product of the erectilized borders of the genital 
furrow, is also completely developed in the male and entirely sur- 
rounds the canal in the pendulous portion. But in the female it aborts 
in the intermediate or vestibular portion, being reduced below to its two 
extremities extending to the bulb of the vestibule, homologue of the 
bulb of the male urethra, but divided by the persistent genital opening; 
and above, it forms the glans of the clitoris, which covers the corpora 
cavernosa clitoridis, homologues of the similar structures in the male 
penis. At the internal part of the bulb of the vestibule there are ves- 
tiges of a membranous organ, which reaches its full development in the 
male — namely, the bulb of the urethra; it is this which forms the hymen. 
Above, joining bulb and hymen to the clitoris and representing the ver- 
tical or cylindrical portion of the masculine corpus spongiosum, there is 
in the female a band with a vascular bundle running into it, the f rsenum 
masculinum vestibuli." (Medical and Surgical Gynecology, vol. ii,p. 436.) 

When the ducts of Mtiller coalesce by the approximation of their 
internal thirds they naturally form a bifurcating double tube divided 
at the lower extremity by a septum with two divergent ends above. As 
development progresses this septum disappears, leaving the rudimen- 
tary vagina below and the rudimentary Fallopian tubes above with no 
intervening uterine body. At the end of the fifth month, however, 
there occurs at the upper end of this rudimentary vagina a deposit of 
tissue, which marks the beginning of the uterus. The failure of the 
septum to disappear from the rudimentary vagina results in the devel- 
opment of a double vagina; while its disappearance from the vagina, 
but its failure to disappear from the uterine extremity of the rudi- 
mentary canal, results in the development of a double, or bicornate, 
uterus. (See Malformations.) 

Malformations of the vulva may lead at the time of birth to an 
erroneous declaration of the sex of the individual, and later on they 
may disqualify for marriage; the importance of vaginal anomalies usu- 
ally becomes apparent when labour is in progress; and the structural 
irregularities of the hymen commonly produce menstrual retention at 
the epoch of puberty, or interfere with the consummation of the act 
of coition some years afterward. 

Malfokmations of the Vulva 

The embryology of the vulva is less clearly understood than 
that of the uterus; it is in consequence of this that its malfor- 
mations have not been so completely systematized as have those that 
affect the uterus. When the changes which take place at the poste- 
rior end of the embryo in connection with the development of the 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 119 



genital tubercle, the cloaca, and the urogenital sinus, are better known, 
the anomalies which arise from interference with the normal course 
of these changes will be more easily comprehended. The complexity 
of the embryogenesis of the neighbourhood of the Bauchstiel is in- 
creased by the occurrence of transitory structures or scaffoldings which 
give place in time to the permanent arrangement of parts, but which 
may, under certain circumstances, persist more or less completely, and 
thus give rise to malformations. A good instance of this permanence 
•of temporary scaffoldings is found in atresia ani vaginalis. 

Vulvar Atresia. — Complete absence of the vulva, the skin passing 
unbroken from the symphysis pubis to the coccyx, is a matter of tera- 
tological interest solely; on the other hand, apparent vulvar atresia, or 
atresia vulvce superficialis, has an immediate importance. On account 
of the existence of labial adhesions, there is an apparent absence of the 
vulvar cleft (Fig. 47). A 
small opening exists an- 
teriorly from, which the 
urine issues sometimes 
with considerable diffi- 
culty. At puberty trouble 
may arise through the oc- 
currence of hematocol- 
pus; but if the opening is 
large enough to permit 
the escape of the men- 
strual fluid, the discovery 
•of the anomaly is post- 
poned till marriage, when 
attempts at penetration 
by the husband may suc- 
ceed in breaking down 
the labial adhesions or 
may require to be supple- 
mented by the knife of 
the surgeon. It is note- 
worthy* that while this 
atresic condition may pre- 
vent coitus, it is not a 
complete obstacle to im- 
pregnation. The treat- 
ment is simple : some- 
times the labia can be 
torn apart, as was done 
by Jan (Indian Lancet, 
vol. vii, p. 123, 1896); at 

other times it may be necessary to pass a sound in at the anterior open- 
ing (Fig. 48), to direct it backward, and then to cut down upon it (Coop, 




Fig. 47. — v- On account of the existence of labial adhe- 
sions, there is an apparent absence of the vulvar 
cleft." — Ballasttyxe. 



120 



A TEXT-BOOK OP GYNECOLOGY 



American Gynecological and Obstetrical Journal, vol. vi, p. 594, 1895). 
When the atresia of the vulva is associated with hypertrophy of the 
clitoris, doubts as to the sex of the individual may arise. 

An anomaly closely allied to that just described consists in the 
existence of preputial and labial adhesions binding down the clitoris. 

This leads to, or is at 
least associated with, 
nervous derangements 
both in childhood and 
adult life. The freeing 
of the clitoris from these 
adhesions may be fol- 
lowed by the disappear- 
ance of symptoms, in this 
respect resembling the 
effect of circumcision in 
the male. 

Infantile Vulva. — In 
infancy the labia majora 
are less developed in 
comparison with the 
other parts, and the vul- 
var cleft is consequently 
more exposed to view; 
the mons also is but 
slightly marked, and 
there is an absence of 
hair. These infantile 
characters may persist in 
adult life. In individuals 
showing this persistence, there is commonly also an imperfect develop- 
ment of the uterus, ovaries, and mammary glands; chlorosis may be pres- 
ent, and the whole clinical picture may be called infantilism in woman. 
Double Vulva.— Only three cases (those reported by Le Cat, 1765; 
Suppinger, 1876; and Chiarleoni, 1894) are on record in which individ- 
uals, otherwise single in formation, possessed two vulvae situated side 
by side in the interfemoral space. In two of these there was an im- 
perforate condition of the anus, the rectum opening into the vulva or 
into the vagina. A case in which the external genital organs of both 
sexes were present was reported by Moostakoff in a Bulgarian journal 
(Meditzina, p. 32, 1894; abstract by Ballantyne in Teratologia, vol. ii, 
p. 234, 1895), and a similar instance (Fig. 49) has been described by 
Neugebauer (Monatsslirift fur Geburtsliulfe und Gynakologie, Bd. vii, p. 
550, 1898). It is probable that in both these latter cases the two sets 
of organs were really of the same sex, one, however, being so deformed 
as to resemble the appearance presented by the part of the opposite sex. 
The corresponding malformation in the male is diphallus, or double- 




Fig. 48. — "It may be necessary to pass a sound in at 
the anterior opening."— Ballantyne (page 119). 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 121 

penis, twenty cases of which, including one personal observation, 
Ballantyne and Skirving (TeratoJogia, Bd. ii, p. 92, 18-1, 255, 1895) 
gathered together and analyzed. Both in diphallus and in double vulva 
there is good reason to believe that the anomaly is truly a duplication 
of the lower end of the trunk — that it is, in fact, the least degree of 
posterior dichotomy. This view is strongly supported by the fact 
that in several of the cases that have been dissected there has been 
discovered bifidity of the lower end of the vertebral column as well as 
duplication of the external genital organs. Ballantyne has reported an 




■•• A case in which the external crenital organs of both sexes were present." — 
Ballaxttxe (page 120 . 

instance of double genital tubercle (without any other trace of exter- 
nal genitals) in a foetus with exomphalos and sacral meningocele 
(Transactions of the Edinburgh Obstetrical Society, vol. xxiii, p. 36, 
1898). 

Persistent Cloaca. — Under the various names of anus vulvalis, vul- 
var anus, atresia ani vaginalis, atresia ani vestibularis, and vulvo- 
vaginal anus, has been described an anomaly which is really due to the 
persistence of the cloacal stage of the development of the female gen- 
erative organs. There is no anal opening in the normal position, but 
fasces pass from the vagina (Fig. 50). Examination reveals an open- 



122 



A TEXT-BOOK OF GYNECOLOGY 



ing, which may be pinhole in size, in the neighbourhood of the hymen 
or at a slightly higher level in the vagina; this is the lower end of 
the rectum. J. W. Ballantyne has recently had a case brought 
under his notice by Dr. George Elder, in which, in a girl four months 
old, there were two vulvar anal openings between the posterior com- 
missure and the hymen; there was a dimple where the normal anus 

should have been. 
Sometimes, but rare- 
ly, the anomaly co- 
exists with a normal 
anal opening. It is 
noteworthy that in 
quite a number of the 
reported cases there 
was control over the 
motions. Under such 
circumstances the 
malformation might 
pass unrecognised till 
after marriage or the 
occurrence of labour. 
When, however, there 
is faecal inconti- 
nence, operation be- 
comes imperative. 
The time of puberty 
is that best suited 
for interference; and 
it is commonly rec- 
ommended that a 
probe be passed in 
at the vulvar end of 
the fistulous tract 
and brought out at 
the spot where the anus ought to be, and that the structures be- 
tween the director and the surface of the perineum be divided and 
the rectum pulled down and fixed by sutures. Buckmaster (Transac- 
tions of the American Gynecological Society, vol. xix, p. 275, 1894), 
however, advises that the rectal canal be brought down in front of the 
sling formed by the fibres of the levator ani muscle and fastened with- 
out strain; that a second operation be performed for the restoration 
of the perineum; and that finally the fibres of the levator ani be split 
so as to form a sphincter very much as has been done with the rectus 
muscle in gastrostomy. 

Persistent Urogenital Sinus. — The name hypospadias in woman has 
been given to the condition in which the urethra appears to open into 
the vagina at a higher level than is normal (Fig. 51); this is really 




Pig. 50. — " There is no anal opening in the normal position, 
but faeces pass from the vagina." — Ballantyne (page 121). 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 123 



persistence of the urogenital sinus, for what is called the lower end of 
the vagina in these cases is more correctly described as the urogenital 
sinus. It differs from persistent cloaca in the fact that the perineum 
and anal opening are normally- 
formed and situated. There 
is a greater or less defect in 
the posterior wall of the 
urethra. Clinically, cases of 
this kind will be grouped ac- 
cording as there is or is not in- 
continence of urine. If there 
is no incontinence, as in the 
case reported by W. A. Ed- 
wards (American Gynecological 
and Obstetrical Journal, vol. 
vi, p. 449, 1896), the individ- 
ual may pass through life and 
even give birth to children 
without the anomaly being de- 
tected. But in the other case 
it will be necessary to operate, 
and the method of Gersuny 
may be adopted, as was done 
with success by Krajewski 
(Bitner, Przeglad Cliirurgicz- 
ny, vol. i, p. 260, 1893-'94). 
The urethra is dissected out 
up to the neck of the bladder, 
the slit in its posterior wall is 

stitched, the canal is then twisted on its long axis, and fixed in position 
by a series of sutures. 

Epispadias in Women. — In women epispadias may be met with as a 
part of the malformation known as extroversion of the bladder, or it 
may exist practically alone. To the latter condition the name is best 
restricted. Ballantyne (Edinburgh Hospital Reports, vol. iv, p. 249, 
1896) has described a case of this kind and gathered together thirty-two 
others from literature. It consists, as in Dranitznr's case (Journal 
AhusJi., vol. viii, p. 567, 1894), in the absence of a greater or smaller 
part of the anterior wall of the urethra, with the division of the cli- 
toris into two parts, and the presence of a median groove in the region 
of the anterior commissure of the vulva (Fig. 52). There is no 
splitting of the symphysis pubis or anterior bladder wall. It has only 
one symptom — more or less complete urinary incontinence — and in its 
least marked form (clitoridian epispadias) even this may be absent. 
Various plastic operations, resembling those used in hypospadias, have 
been employed to lengthen and narrow the urethra and to restore the 
anterior vulvar commissure and clitoris; but success has only been occa- 




Fig. 51. — " The name hypospadias has been given 
to the condition in which the urethra appeal's 
to open into the vagina at a higher level than 
is normal." — Ballantyxe (page 122). 



124 



A TEXT-BOOK OF GYNECOLOGY 



■ 



I 



sionally obtained, and most often the purely palliative wearing of a 
urinal has had to be accepted as the sole treatment practicable. 

Precocious Development 
of the Vulva. — In strong con- 
trast to the cases of infantile 
vulva are those of precocious 
development of it, which are 
occasionally met with. Girls 
of from two to ten years ex- 
hibit under these circum- 
stances a marked growth of 
pubic hair; the vulva, as in 
the adult, is strongly devel- 
oped anteriorly (de Kiche- 
mond, Revue mensuelles des 
maladies de Venfance, tome 
xvii, p. 74, 1899); and the 
mammary glands may also 
show hypertrophy. Physio- 
logically there may be early 
menstruation or pubertas 
prsecox (Hennig, CentraTblatt 
fur Gynakologie, Bd. xxii, p. 
832, 1898), and in some in- 
stances (e. g., that reported 
by C. W. Gleaves, Medical 
Record, New York, November 
16, 1895) there has been pre- 
cocious pregnancy. 

Malformations of the 
Labia, Clitoris, and Peri- 
neum. — The anomalies that 
have been described affect more or less all the structures mak- 
ing up the vulva, but the single parts may also be malformed. The 
labia minora or nymphae may be absent, or increased in number, or 
hypertrophied; the clitoris also may be enlarged so as to suggest doubts 
as to the real sex of the individual. In many of these cases of hyper- 
trophy there exist nervous phenomena, which are occasionally miti- 
gated by excision of the enlarged parts. A curious anomaly of the labia 
minora has recently been reported by Shoemaker {American Journal of 
Obstetrics, vol. xxxii, p. 216, 1895); the nymphas were unusually large, 
and in each there was a congenital circular perforation about half an 
inch in diameter, and exactly opposite each other. J. W. Ballantyne 
has described a case of a suspected " hermaphrodite " in which the 
left nympha was enlarged, p3 r ramidal, and divided into two parts by a 
constriction {Transactions of the Edinburgh Obstetrical Society, vol. 
xiii, p. 185, 1898). 



■: ;. ::. . 



Fig. 52. — " Epispadias may be met with as part 
of the malformation known as extroversion of 
the bladder." — Ballantyne (page 123). 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 125 



Pseudo-hermaphroditism : Masculine. — It is not out of place in a 
work devoted to gynecology to refer to cases of doubtful sex in which, 
the individual, by reason of his possession of testicles, is a male, but on 
account of his external organs might quite well be a woman, for such 
cases usually are brought to gynecologists for treatment. The anomaly 
most commonly met with under these circumstances is perineo-scrotal 
hypospadias (Fig. 53). The imperforate penis, often atrophic, re- 
sembles the clitoris; the ure- 
thra opening at the base of 
this rudimentary penis re- 
sembles the female meatus 
urinarius at the base of the 
vestibule; and the short ves- 
tibular canal, which may 
even be guarded by a hymen, 
simulates the vaginal orifice 
in a very striking fashion. 
Nondescent or atrophy of the 
testicles, enlargement of the 
mammary glands, and the 
exhibition of acquired femi- 
nine traits, may all combine 
to make the question of the 
sex of the hypospadia male 
one of the greatest difficulty. 
When it is added that cases 
have occurred in which the 
individual not only possessed 
a uterus, but also suffered 
every month from a san- 
guineous discharge from it, 
the discovery of the true sex 
only after post - mortem 
microscopic examination of 
the genital glands can be 
quite well understood. It 
must also be remembered 
that the testicles in such 

cases often show pathologic changes. In an individual described by 
P. Delageniere (Annates de gynecologie, tome li, p. 57, 1899), and 
regarded for twenty-seven years as a woman, the testicles, which were 
found in the inguinal regions, showed tubules surrounded by fibrous 
tissue, atrophied, and containing no spermatozoa. In one of the 
glands there were also several nodules, " adenomata of the testicle." 
In this case the vulva was absolutely normal, the breasts were 
those of a girl before puberty, and the thorax was masculine in 
type. The abdomen was opened, but no trace was found of uterus or 




Fig. 53. — " The anomaly most commonly met with 
is perineo-scrotal hypospadias." — Ballantyne. 



126 A TEXT-BOOK OF GYNECOLOGY 

tubes; the atrophied testicles were removed. If such individuals are 
seen at the time of birth it is probably best to bring them up as boys, 
as Lawson Tait suggests, for male pseudo-hermaphrodites are com- 
moner than females, and there is less risk in bringing up a girl among 
boys than a boy among girls. At a later age the question of removal 
of the genital glands (nearly always atrophic or morbid either in 
structure or position) will require to be faced. C. Martin has removed 
the testicles from an individual brought up as a girl, with the result or 
sequence that the pubic hair and the breasts developed (British Medical 
Journal, vol. i, 189-4, p. 1361); but it is doubtful to what extent we are 
at liberty in these cases to remove sexual glands even when these are 
in all probability morbid in structure and possibly functionally inade- 
quate. 

Pseudo-hermaphroditism : Feminine. — The most common form of 
gynandria or feminine pseudo-hermaphroditism, is that in which 
superficial vulvar atresia exists' in association with hypertrophy of the 
clitoris. When there is also hernia of the ovaries into the labia the 
individual may readily be regarded as a male. In all probability, how- 
ever, doubts will early arise as to the true sex, and a close inspection of 
the parts, accompanied possibly by some slight surgical interference, 
will serve to make plain the matter before any harm is done. 

Malfokmations of the Vagixa 

The embryology of the vagina is better understood than that of the 
vulva, and the nature of its anomalies is therefore more evident. Some 
doubt, however, exists as to the mode of formation of the lower end of 
the canal and of the hymen. The general view is that the whole of 
the vagina above the hymen is Mullerian in origin, being produced by 
canalization of the fused lower ends of the two ducts of Miiller; but 
Berry Hart (Transactions of the Edinburgh Obstetrical Society, vol. 
xxii, p. 18, 1897) looks upon it as Mullerian in its upper part only, and 
as developed from the urogenital sinus in its lower third by the break- 
ing down of cells derived from the Wolffian bulbs (lower ends of the 
Wolffian ducts). Nageh's investigations, however, do not support Hart's 
conclusions, and Webster (Transactions of the American Gynecological 
Society, vol. xxiii, p. 446, 1898) also sums up adversely to them. Nev- 
ertheless the anomalies of the vagina present features not easily ac- 
counted for by either of the two theories of origin. 

Absence of the Vagina. — Cases of complete absence of the vagina, 
in which careful examination of the tissues lying between the rectum 
and the bladder reveals no trace of muscular bands, are of pathological 
interest solely; they occur only in connection with advanced terato- 
logical conditions, such as sympodia. 

Vaginal Atresia. — There may exist a complete or an incomplete 
imperforate condition of the vagina; between the bladder and rectum 
there may be found simply a fibro-muscular cord; in other cases the 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 127 




vaginal canal may be present in part and imperforate in part; and in 
yet others there may be a membranous septum at the upper, middle, or 
lower, third of the vagina. When the lower third of the canal alone 
is present it is surmised that it is not Miillerian, but derived from the 
vestibular sinus; its upper boundary would be composed of the lower 
imperforate end of the Miillerian vagina, or (if the theory of Hart is 
accepted) of the persistent Wolffian bulbs. The malformed state of the 
vagina is commonly associated with anomalies in the other genital 
organs both internal and external; thus, the uterus may be ill devel- 
oped or absent, and the Fallopian tubes and vulva may, but not so 
frequently as the uterus, be 
defective. On the other 
hand, the uterus and the 
other genitals may be normal 
in structure. Sometimes it is 
stated that the ovaries are 
absent, but it must be re- 
marked that in cases in 
which the vagina and ovaries 
are both absent the sex of the 
individual can hardly be re- 
garded as female at all. If 
functionally active ovaries 
and uterus coexist with im- 
perforation of the vagina, 
the supervention of puberty 
usually leads to the retention 
of blood, in a more or less 
altered state, in the uterus 
(hematometra) or tubes 
(hematosalpinx), or in the 
perforate part of the vagina 
(hematocolpus) (Fig. 54). J. 
W. Ballantyne has recently 
seen a case (under the care 
of Dr. Alexander James in 
the Edinburgh Infirmary) in 
which the vagina was imper- tyne. 

forate in a great part of its 

extent, and in which the uterus was the size of a three months' preg- 
nancy (hematometra); the patient, a girl twenty-two years of age, had 
frequently recurring attacks of epistaxis, and a very remarkable fea- 
ture of the morbid anatomy was the presence of well-marked cervi- 
cal ribs. 

Clinically, an imperforate condition of the vagina usually begins to 
attract notice when the individual reaches the age of puberty. As 
month after month goes past without any sign of the menstrual dis- 








Fig. 54.— "The supervention of puberty usually 
leads to the retention of blood in the perforate 
part of the vagina (hematocolpus)."— Ballan- 



128 A TEXT-BOOK OF GYNECOLOGY 

charge, but with all the signs associated with menstruation (pain and 
weight in the pelvis, headache, swelling of the breasts, epistaxis, etc.), 
the patient's friends bring her to a medical practitioner. It is then 
found that the vagina is imperforate and that there is distention in the 
hypogastric region, and, if the case is kept under observation, it may 
be noted that this swelling increases suddenly at recurring monthly 
periods, to diminish again slowly in the intervals. The examining 
finger passes into the vagina to a greater or lesser distance, accord- 
ing as the imperforation is high up or low down in the canal, but it 
never touches the cervix, and by the aid of the rectal touch, with a sound 
in the bladder perhaps, it can be made out whether the uterus and 
adnexa are present or not, and whether there is menstrual retention in 
the uterus and tubes or not. In other cases of vaginal atresia, the first 
symptoms to lead to medical intervention are those arising at the time 
of marriage, when coitus is found to be either impossible or incomplete 
and painful. In these instances the internal genital organs may be 
functionally quiescent, a fact which accounts for the absence of 
monthly suffering and for the late discovery of the vaginal anomaly. 

The intervention of the gynecologist in cases of imperforate vagina 
may be rendered necessary under two sets of circumstances — at or soon 
after puberty, for monthly pain and for hematometra and the symp- 
toms associated therewith; or at the time of marriage for dyspareunia. 
Under the former circumstances, the object of intervention is to reach 
and evacuate the retained menstrual blood; under the latter, it is 
mainly to establish what may be called a coitional vagina by a plastic 
operation. 

If the vaginal atresia is situated near the introitus and is localized, 
then a simple crucial incision will serve to set free the more or less 
altered blood in the upper part of the canal; the evacuation should be 
■carried out without haste and strict surgical cleanliness observed. If, 
on the other hand, the atresia is extensive and the blood accumulation 
is far from the surface, very careful dissection will be needed before the 
cervix uteri is reached. With the sound in the bladder and a finger in 
the rectum, and using the handle of the knife or probe-pointed scissors, 
the operator will work upward toward the blood accumulation (whose 
position has been determined by rectal touch), will incise the sac, and 
endeavour, with the aid of flaps derived from the labia minora and 
perineum, to form a vaginal canal. Possibly in the future the method 
of operating recommended by P. Walton (Belgique medicate, ann. 5, p. 
353, September 22, 1898) will take the place of that described above as 
more speedy and scarcely more dangerous. He makes an H -shaped 
incision between the labia minora, dissects upward, and at once opens 
into the peritoneal cavity (instead of avoiding it, as has been the cus- 
tom) through the pouch of Douglas; he then passes his 'fingers in and 
ascertains the condition of the uterus and adnexa; the opening in the 
peritoneum can then be closed with catgut sutures and the construction 
of the artificial vagina proceeded with. In the case operated upon by 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 129 

Walton, five months had elapsed since the formation of the canal and 
menstruation had occurred regularly, although in small amount and 
with complete absence of suffering. The results recently obtained by 
posterior colpotomy for other conditions support Walton in his recom- 
mendation; certainly the operation is greatly shortened, and an accu- 
rate knowledge of the position and condition of the parts is obtained. 

It is doubtful to what extent the gynecologist is justified in recom- 
mending the creation of an artificial vagina when no menstrual suffer- 
ings exist, and when there is consequently no reason to suppose that 
functional internal organs are present, for the operation, which is not 
free from risk, is manifestly being undertaken solely to provide a 
coitional vagina. Should intervention, however, be decided upon, it 
will be best to dissect upward in the space between the rectum and 
bladder to a distance of about two inches, and then to line this in- 
vagination with tissue obtained from the nymphae and perineum. The 
cavity will require to be kept open for some time with a cone-shaped 
pessary. 

Vaginal Stenosis. — An abnormal degree of narrowness of the vagina 
may be met with and may affect the whole canal or only a part of it. 
When the stenosis is general, it probably means that we have to do with 
a half vagina derived from one MfOlerian duct, the other half being 
undeveloped, or at least imperforate. Then the condition may be asso- 
ciated with the uterus unicornis or bicornis (with one cornu rudimen- 
tary). In other cases the stenosis is annular, and consists of one or 
more perforated diaphragms, a condition which may have been pro- 
duced by adhesive colpitis in infancy or in foetal life, but which more 
probably represents incomplete canalization of the vaginal anlage. 
Dyspareunia may result at the time of marriage, or delay may occur 
during the second stage of labour, and the anomaly thus be brought 
under the notice of the gynecologist. It is usually recommended that 
a crucial incision be made and the ring stretched; but it will be more 
satisfactory to adopt the plan advocated by Yineberg (American Gyne- 
cological and Obstetrical Journal, vol. vi, p. 250, 1895), which consists 
in excision of the septum and ihe bringing together with sutures 
of the upper and lower margins of the annular incision thus produced. 

Double or Septate Vagina. — The term double vagina should in strict 
accuracy be applied only to those cases in which there exist two uteri 
and two vulvar apertures in addition to the two vagina?; such cases, as 
has been stated already, are exceedingly rare, and must be grouped 
among the double monstrosities. On the other hand, septate vagina, 
which is usually named c * double " vagina, is much more common. It 
is due to want of fusion of the two Miillerian ducts in their lower part; 
it is not, therefore, an anomaly by excess, but by defect, an arrested 
development. The septum generally runs antero-posteriorly, when, of 
course, the vaginae are situated laterally; rarely, as in a case reported by 
Fordyce (Teratologia, vol. i, p. 72, 1894). the canals lie one in front of 
the other and the septum is transverse. The septum may be complete 
10 



130 



A TEXT-BOOK OF GYNECOLOGY 



and may extend from a point above between the two cervices (there are 
often two vaginal portions, indicating a double uterus) to the vulvar 
aperture, where it may subdivide that orifice and produce what is 
called a hymen biforis; on the other hand, it may exist in the upper 
part of the vagina alone, or in the lower part alone, or it may show a 
varying number of perforations. 

Clinically, septate vagina may give rise to no symptoms till parturi- 
tion occurs, when, as in a case recorded by Eanieri (Annali di ostetricia 
e ginecologia, xvi, p. 473, 1894), excision of the septum may be needed 
during the labour to prevent laceration of it, which might entail also 
laceration of the uterus. When, however, one or both halves of the 
vagina are imperforate (a not uncommon occurrence in septate vagina, 

Fig. 55) symptoms will 
arise about the time of 
puberty in association 
with the retention of 
blood in one or both 
canals (unilateral or 
bilateral hematocolpus). 
When unilateral, this 
condition has been called 
atresia vaginae lateralis. 
Since the retention of 
blood may cause pain 
in the back and difficulty 
in micturition and defe- 
cation, it will be neces- 
sary to incise (or better 
to excise) the sac, clear 
out its contents, and 
pack with iodoform 
gauze under antiseptic 
precautions. In all cases 
in which an elastic swell- 
ing is found in the vag- 
inal wall, the possibil- 
ity of its being an im- 
perforate half vagina 
communicating with a 
functionally active half 
uterus should be borne 
mind. In a case 




in 



Fig. 55. — " Both halves of the vagina are imper- 
forate." — Ballantyne. 

seen by Muret (Revue 
medicate de la Suisse romande, p. 280, May 20, 1895) the better devel- 
oped half was imperforate and the more rudimentary one was patent. 
Sometimes the imperforate half communicates with the patent by 
means of a small opening, when dysmenorrhcea may exist without com- 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 131 

plete menstrual retention. In Fordyce's case (loc. cit.) both halves 
opened into the urethra. 

The Hymen. — This structure, which marks the dividing line be- 
tween the vulva and the vagina, has been carefully studied by Schaeffer 
in nearly two hundred foetuses. He found, without exception, that as 
early as the fifth month the hymen was composed of two lamellae, the 
inner being derived from the vagina, while the outer appeared to be the 
inner margin of the vulvar fold; and that coalescence of these two 
layers was not infrequent. On the vaginal surface of the hymen were 
found transverse folds, similar to those in the vagina, between which 
were pockets so distinct that, in the event of their occlusion, they could 
easily be converted into retention cysts. Irregularities in the distri- 
bution of these folds account for those anomalies of the hymen which 
are spoken of under the names of hymen crenulatus, dentatus, carinatus, 
falciformis, etc. On the vulvar surface of the hymen in the foetus, 
he found numerous folds extending from the fossa navicularis, 
nymphae, clitoris, and meatus. If these observations meet with suffi- 
cient confirmation, it may be necessary to revise accepted theories of the 
embryologic development of this structure. At present it is looked 
upon as a remnant of the cloacal appendage. In the human embryos 
shortly after the coalescence of Muller's ducts it manifests itself by 
an accumulation of epithelia on the posterior wall of the rudimen- 
tary vagina. Whether it develops entirety from the vulvar side or 
entirely from the vaginal side, or, as is more probable, in two lamellae, 
one from either side, is a matter of no practical importance. To the 
naked eye it presents the appearance of a mucous fold that in many 
instances is very elastic. The elasticity of this structure is so pro- 
nounced in a number of cases that it withstands repeated parturition. 
Microscopically, its surfaces are shown to be covered with flat epi- 
thelium on a network of fibrous elastic tissue, containing few or no 
muscular fibres. Capillary vessels and nerves are conducted by nu- 
merous papillae from the central connective tissues into the epithelial 
structures. 

Malformations of the Hymen 

The hymen is a developmental relic, and is, therefore, very liable 
to variations in form and structure. It arises from the breaking down 
of the tissue between the sinus urogenitalis and the lower end of the 
Miillerian vagina, and it is possible, as Hart asserts, that the Wolffian 
bulbs may contribute to its formation. In addition to the well-known 
part of it which forms a crescentic fold at the posterior end of the 
vulvar aperture, the hymen consists of a mesial band running forward 
toward the clitoris, and forming a collar for the meatus urinarius on 
the way. Attention was specially drawn to this forward extension of 
the hymen by Pozzi (An?iales de gynecologies tome xxi, p. 257, 1884), and 
J. W. Ballantyne has described the appearances presented by the mesial 
vestibular band in female infants (Fig. 56) (Transactions of the Edin- 



132 



A TEXT-BOOK OF GYNECOLOGY 



burgh Obstetrical Society, vol. xiii, p. 188, 1888). Anomalies may be met 
with, in the vestibular portion as well as in the hymen commonly so- 
called, and even a dis- 
tinct projection may exist 
(Fig. 57). 

Hymenal Atresia or 
Imperforation. — It is ex- 
tremely probable that 
many of the cases de- 
scribed as instances of 
imperforate hymen are 
really examples of atresia 
of the lower end of the 
vagina, for in some of 
the records the presence 
of a hymenal membrane 
hidden by the projecting 
vaginal sac is referred to. 
On the other hand, un- 
doubted cases of atresia 
hymenalis do occur. The 
imperforate condition of 
the membrane gives rise 
to symptoms which can 
scarcely be distinguished 
from those of atresia of 
the lower part of the 
vagina. During infancy 
some trouble may be 
caused by the retention 
of mucus in the canal, 
but it is usually not till 
puberty that the condition attracts notice. Every month, colicky pains 
recur with increasing severity; there is some difficulty with micturition 
and defecation, which passes off 
in the intermenstrual period; there 
may be epistaxis or vicarious 
hemorrhage from the bladder or 
bowel; but there is no discharge 
from the genitals. Examination 
of the patient at one of these 
epochs will reveal a fluctuating 
tumour projecting to a larger or 
smaller extent above the symphy- 
sis pubis, according as the condi- 
tion has been persisting for a longer or shorter time; and in the vulva 
will be seen a bulging membrane, which is the distended hymen. The 



1 


i 


EH 


1 1 


1 




% e, 


• 


■j 


















i" : 








W 






HOPMte 



Fig. 56. — " The appearances presented by the mesial ves- 
tibular band in female infants." — Ballantyne (p. 131). 




Fig. 57. — "Even a distinct projection may 
exist" (section). — Ballantyne. 



THE EXTERNAL ORGANS OF GENERATION IN WOMEN 133 

condition of hematocolpus, which has been thus produced, may be ac- 
companied by the accumulation of blood in the uterus also (hemato- 
metra). F. Neugebauer (Medycyna, vol. xxi, p. 429, 1893) has recorded 
an unusual case of hymenal imperforation without menstrual retention, 
the blood escaping through a small opening at the right side of the 
urethra; the hymen is described as consisting of two laminae (hymen 
lilamellatus), an external incomplete and an internal complete, so that 
it is likely that the internal one was really the lower end of the imper- 
forate vagina. 

The first step in the treatment of hymenal imperforation consists 
in the evacuation of the retained menstrual blood. The membrane is 
incised and the fluid removed under antiseptic precautions, the latter 
being specially necessary if the uterus and Fallopian tubes have shared 
in the distention. The remnants of the hymen are then excised, and 
the edges are brought together with sutures. The cavity is packed with 
iodoform gauze. The removal of the more or less altered blood should 
be done slowly. 

Double Hymen. — The cases in which two (or more) diaphragms 
exist near the vaginal outlet should not, perhaps, be regarded as in- 
stances of double hymen, but rather as examples of annular vaginal 
stenosis. Neither does the existence of two openings in the hymen con- 
stitute a double hymen in the strict sense of the words. The term 
ought to be left for the very rare instances, to which reference has 
already been made, in which two vulvae exist side by side in the inter- 
femoral region. 

Absence of the Hymen. — The hymen is rarely completely wanting 
except in connection with absence of all the external genitals, as in 
some marked forms of monstrosity; but it may be apparently absent, 
being hidden from view by the bulging lower end of an imperforate 
vagina. In the newborn infant, it is folded together and projects from 
the vaginal orifice as two lateral folds, which may be taken for the 
labia minora. In the negro infant, it is deeply seated, and may in con- 
sequence be thought, on casual inspection, to be absent. 

Anomalies in the Form of the Hymen. — Instead of its normal cres- 
centic form, the hymen may be circular (Fig. 56), or notched (denticu- 
late), or projecting (infundibuliform), or fimbriated. Instead of bound- 
ing one orifice it may show two openings, which may be equal in size 
and situated laterally (hymen septus), or unequal in size and situated 
irregularly (hymen bifenestratus); in rare cases there may be several 
openings (hymen cribriformis). J. W. Ballantyne recently met with an 
instance of very complete hymen septus in an unmarried woman of 
forty upon whom he was operating for hemorrhoids; the openings were 
perfectly equal in size, and the septum, which was quite fleshy, extended 
for some distance up the vagina; the uterus was single, as was also the 
upper part of the vagina. 

Anomalies in the Structure of the Hymen. — The hymen, especially 
in elderly primiparae, may be very tough and resistant; it may on this 



134 A TEXT-BOOK OF GYNECOLOGY 

account delay the dilatation of the perineum in labour; it may even 
prevent the consummation of marriage, and require to be excised, as 
in a case seen by J. W. Ballantyne {Transactions of the Edinburgh 
Obstetrical Society, vol. xiv, p. 141, 1889). If it is very vascular, as 
well as very tough, the laceration it undergoes in coitus may cause 
alarming hemorrhage. 

Anomalies in the Anterior Extension of the Hymen (Urethral 
Hymen and Vestibular Band). — Gilliam has described two cases of what 
would seem to be a persistence of the anterior extension of the hymen, 
which surrounds the meatus urinarius like a collar. In one of these, 
that of a girl of eighteen, suffering from incontinence of urine, there 
was an anomalous band attached to the urethra and spreading itself 
over the muscles of the anterior aspect of the vulvo-vaginal junction; 
it was clipped, and the incontinence disappeared at once. In the other 
case, that of a girl of twenty-one, also suffering from urinary inconti- 
nence, a membrane stretched from the anterior segment of the hymen 
and was attached like wings to the sides and under surface of the 
urethra; its excision gave a cure. Gilliam (American Journal of Ob- 
stetrics, vol. xxxiii, p. 177, 1896) thinks that these bands set up local 
irritation. 



CHAPTEE XIV 

INJURIES OF THE EXTERNAL GENITAL ORGANS 

Injuries of the vulva from external violence, sexual intercourse, parturition — Pu- 
dendal hematocele — Injuries of the vagina: Rupture — Fistula?: urethrovag- 
inal, vesico-vaginal — Sims's operation — Ross's operation — Reed's operation — 
After-treatment and dangers — Atresia of upper part of urethra — Uretero- 
vaginal fistula? — Recto-vaginal fistula — Mayo Robson's operation. 

Injueies of the external organs of generation may, for convenience 
of study, be classified into those involving (a) the vulva, and (b) the 
vagina. On account of the anatomical position of the vulva, which is 
protected above by the mons veneris and the underlying hard and 
resisting symphysis pubis, the descending rami, and the inner aspect of 
the thighs, injuries to this structure, except when due to parturition, 
are necessarily rare. 

The vascularity of the tissues composing the vulva predisposes the 
structure to profuse hemorrhage, so that, should there be a solution of 
continuity of the skin, the loss of blood may be considerable, even 
amounting to syncope in weak and debilitated individuals. 

In considering these injuries the anatomical construction of the 
surrounding and underlying parts must be borne in mind. The rami 
of the pubis possessing a rather sharp inner edge, a blunt instrument 
may be used, and yet an incised wound may be the result, the blunt 
object forcing the overlying soft structures against the ramus. Con- 
tused rather than incised wounds are, however, the rule. 

In instances in which the skin is not divided, hemorrhage into the 
abundant connective tissue here found results in hematoceles of vary- 
ing sizes, according to the size and number of blood vessels injured. 

The causes of these injuries to the vulva may be considered under 
three headings — viz.: (a) External violence, (b) coitus, (c) parturition. 

External Violence. — The patient may fall astride the back of a 
chair, as in the case of servants engaged in cleaning windows, hanging 
curtains, and pictures; or in the case of the female bicyclist being 
thrown from the saddle and alighting on the iron frame or handle bar. 
Eoss, of Toronto, reports (American Journal of Obstetrics, April, 1898) 
a case in which a woman, while riding her wheel, was thrown from the 
saddle, and alighting on the sharp portion of the frame, tore the geni- 
talia upward as high as the erectile tissue near the clitoris, producing 
copious hemorrhage. Hemorrhage from the vulva may be fatal even 

"l35 



136 A TEXT-BOOK OF GYNECOLOGY 

when induced by a relatively slight injury. Ford (New York Medical 
Journal) reports a case of hemorrhage resulting in death in a patient 
who, while at the theatre, in attempting to 'change her seat, fell against 
the iron partition between the chairs, inducing a lacerated wound, 
about a third of an inch in diameter, between the clitoris and the 
labium minus. If the injury to the deeper structures is induced by 
pressure against the ramus of the pubis and does not result in severing 
the continuity of the skin, the resulting hemorrhage takes the form 
of a hematocele. (See Pudendal Hematocele.) 

Among other wounds of the vulva are those produced in children 
while at play: A fall upon a picket fence; splinters of wood being forced 
into the labia while sliding upon the floor or down an incline; and falls 
from sleds while coasting, etc. 

Injuries to the vulva by sexual intercourse, aside from slight lacera- 
tions of the fourchette, are of very rare occurrence, except in cases of 
rape of children and of women of advanced age. In the former they are 
due to the tender and undeveloped soft parts, and in the latter to senile 
atrophy and consequent want of elasticity. These lacerations generally 
involve the hymen in the young and the fourchette in the aged, and 
extend thence in various directions. Baldy reported (American Gyne- 
cological Journal, 1891) a case of laceration due to first intercourse, 
the injury beginning at the hymen and extending upward on the 
vaginal aspect of the perineum. Spaeth records a case (American 
Journal of Obstetrics, 1890) of laceration beginning at the vulvar 
orifice, extending upward along the posterior wall of the vagina, 
causing a vesico-rectal fistula. 

Parturition is by far the most frequent cause of injuries to the 
pudenda. (See Pudendal Hematocele.) Here also the perineum suf- 
fers the greatest injury. Contusions of the labia, and sometimes of the 
vulvo-vaginal glands, are due, in the majority of instances, to a failure 
of the head to rotate into the conjugate diameter of the outlet of the 
pelvis. Not infrequently also does the careless use of the forceps cause 
lacerations and contusions of these parts. 

Treatment. — The treatment of injuries of the pudenda does not dif- 
fer greatly from that of like injuries inflicted elsewhere. The parts 
should be well shaven, washed, and antisepticized, and lacerations and 
incisions sewn up. If contusions only are to be dealt with, the carbolic 
pack is applied. This dressing is prepared in the following manner: 
Flakes of absorbent cotton are first saturated with a 1- or 2-per-cent 
solution of carbolic acid, then squeezed out almost dry and applied 
to the antisepticized injured part. Over this are applied flakes of dry 
cotton, and the whole is covered with rubber tissue or oil silk. The 
dressing is held in place by a properly adjusted T-bandage. A dressing 
thus applied will last from six to ten hours. Further treatment is 
given in the section relating to Pudendal Hematocele. 

Pudendal hematocele may be the result of a blow, a kick, or a 
fall; or, in the pregnant state, of varices preceding labour, the 



INJURIES OF THE EXTERNAL GENITAL ORGANS 137 

pressure of the descending head, or the unskilful use of forceps. 
M. A. Tate, of Cincinnati, who has conducted a painstaking research 
on this subject (Lancet-Clinic, October 17, 1896), finds that it was 
first mentioned by Rueff, of Zurich, in 1647; in IT 31 by Kronauer, 
of Basle; and again, a hundred years later, by Deneaux, from which date 
(1830) reports of cases have been relatively more frequent. When it 
occurs, from whatever cause, the clot generally forms in one labium, 
although in certain cases its progressive accumulation results in sepa- 
rating the connective tissue of practically the entire pudendum. The 
tumour thus formed may therefore vary in size from very small to 
very large, Cazeaux reporting one case in which the extravasation was so 
extensive that it ploughed up the abdominal wall of the right side to the 
costal margin. Occasionally the rupture occurs in the wall of the 
vagina, and only reaches the vulva by an extension of the accumulation, 
while in other cases the hematoma is confined to the vaginal wall. 
Sometimes, the distention becomes so great that the skin or mucous- 
membrane gives way and the blood clot escapes. If the hematocele is 
the result of rupture of an artery, the hemorrhage resulting from the 
breaking down of the skin may become active, even after the clot has 
been in situ for a number of days. In small accumulations the clot 
may be absorbed; in others, where the pressure of the integument is 
very great, or where the contusion has been extensive and severe, gan- 
grene may result. In occasional cases the clot may become solidified, 
even to the extent of calcification. The symptoms of pudendal hemato- 
cele consist of swelling of the labia, with pain in the parts, which, even 
in the midst of the pains of labour, is generally sufficiently severe to 
attract the attention of the patient. The tumour increases rapidly in 
size and at first is usually without any change of colour in the skin,. 
but later becomes pinkish and bluish, and finally, when absorption 
is well under way, it becomes brown or bronzed in appearance. This 
tumour is generally at first very tense, but later, as absorption or sup- 
puration takes place, becomes softer and more fluctuating. Its forma- 
tion may be attended with some shock, corresponding in degree to 
the severity of the causative injury or the amount of the extravasated 
blood. The rarity of this complication of labour, says Sasonoff 
(Archives de gynecologies Xovember, 1881), will be appreciated when 
it is remembered that AVinckel noted only one case out of 1,600 
confinements; Hecker, two cases out of IT. 2 00; Spiegelberg, three out 
of 3,000; and that, at the St. Petersburg Maternity, there have occurred 
only eight cases out of 19,396 labours. Generally, then, it may 
be said that this complication occurs but once in 2,3 T5 labours. The 
prognosis of these cases, so far as life is concerned, is favourable, and 
hematocele is rarely, if ever, fatal from the loss of blood, unless there 
is secondary rupture, when the subcutaneous extravasation becomes 
converted into a free hemorrhage. These injuries, however, are in many 
instances associated with enough superficial destruction of tissue to 
serve as an infection atrium, with the result that the underlying clot is 



138 A TEXT-BOOK OF GYNECOLOGY 

very liable in the course of the next few days to become converted into 
a culture medium for the propagation of pyogenic bacteria. As a com- 
plication of labour, pudendal hematocele is looked upon by both Play- 
fair and Cazeaux as very serious. Tate (he. cit.) has collected cases of 
pudendal hematocele occurring as a complication of labour as follows: 





Cases. 


Fatal. 


Playfair (collected by various French authors). . 
Scanzoni 


124 
15 
62 
22 
19 
50 


44 
1 


Deneaux 


22 


Barker 


3 


Blot 


5 


Winckel 


6 






Total 


292 


81 







It must be remembered, however, that in explaining the mortality 
of 81 in a total of 292 cases from an accident intrinsically so controlla- 
ble as pudendal hematocele, an important percentage of these cases 
occurred before the inauguration of the present antiseptic regime. It 
is true that of these cases, but three, those reported by Barker, were 
recorded as having died from sepsis; but this fact does not exclude the 
extreme possibility that an important number of the remaining deaths 
occurred from the same cause. 

The treatment should vary a little according as the hematocele is the 
result of external violence or of parturition, and according to the size 
of the clot. If external violence is the cause, and if the clot is large, and 
has developed, or is developing, with rapidity, there is strong probabil- 
ity that it is being fed by a severed artery, under which circumstances 
the patient should be anaesthetized and the bleeding points found and 
ligated. If, however, the clot has formed slowly, and is not large, it 
should be treated with rest and the application of ice bags. If, after 
a few days, the tumour becomes red about its circumference and the 
pain, of a pulsating character, shows a tendency to increase, and if there 
is some elevation of temperature, the clot may be considered to be 
the seat of incipient suppuration and should be freely incised, its cav- 
ity thoroughly cleansed, first with the hydrogen peroxide, and next 
with a l-to-2,000 mercuric bichloride solution. 

If a hematocele occurs as a complication of labour, rather more 
chances should be taken to secure its absorption; as a free incision in 
the presence of the probably contaminated lochia may be far from 
an innocent procedure. It should be remembered that there exists 
the reciprocal danger of liberating into the vagina, or, at least, about 
its orifice, pathogenic bacteria that have developed in the pus of a 
suppurating hematocele. A pudendal hematocele in a parturient case 
should, therefore, be opened only in the presence of the most positive 
indications, after which its treatment should be conducted on lines of 
the most rigorous and persistent antisepsis. 



INJURIES OF THE EXTERNAL GENITAL ORGANS 139 

Injuries to the external genital organs due to parturition, aside 
from pudendal hematocele which has just been considered, occur in (a) 
the perineum (see Pelvic Floor and its Injuries), and (&) the vagina. 
Of the injuries to the vagina, the chief ones are rupture and fistulae. 

Injuries of the Vagina. — Rupture may occur at any place, although 
it is more common in the posterior than in the anterior wall. Such 
lacerations have occurred through the vault of the vagina into Douglas's 
cul-de-sac and through the recto-vaginal septum. They have occurred 
also in the fornices, splitting up the broad ligament and causing dan- 
gerous hemorrhage, by severing the important blood vessels that lie 
upon either side of the vaginal tract. When these lacerations occur, 
they should be immediately cleansed, and the usually contused and 
roughly lacerated margins of the wound pared off and approximated 
by interrupted nonabsorbent sutures. Many of these lacerations pass 
without recognition and heal spontaneously by the formation of irregu- 
lar cicatrices which narrow the vagina in an irregular way, causing 
dyspareunia and other distressing symptoms. 

Rupture of the vagina is to be looked upon as a tear due to the 
joint influence of an expansive force and to the inelasticity of the 
canal. It may result in the formation of a fistula, but a rupture is to be 
distinguished from a fistula in the particular, that while a tear is 
caused as already indicated, fistula is generally the result of prolonged 
pressure and subsequent necrotic changes. 

Fistulae. — A fistula is an unnatural channel that leads from a cuta- 
neous or a mucous surface to another free surface, or that terminates 
blindly in the substance of an organ or part. The edges of such open- 
ings are covered with epithelium. The forms of fistula that are met 
with in the female genital tract are urinary and faecal. 

Urinary Fistula'. Fwcal Fistulce. 

Urethro- vaginal. Eecto-perineal. 

Vesico-vaginal. Eecto-vaginal. 

Vesico-uterine. Entero-vaginal. 

Uretero-vaginal. 
Ur etero-uterine . 

Urinary Fistulae (Urethro-vaginal, Vesico-vaginal). — The variety 
most commonly met with is the vesico-vaginal (Fig. 58). It sometimes 
happens that a fistula exists between the bladder and the vagina, and, 
at the same time, that the urethra has been partially or totally de- 
stroyed. A vesico-vaginal fistula may vary very much in size. At 
times it is so large that the mucous membrane of the bladder prolapses 
through it and the bladder is almost turned inside out. The mucous 
membrane is easily recognised by its bright-red colour. At other times 
the fistula is only large enough to admit a small probe. The nearer 
to the time at which the fistula was caused, the larger is the open- 
ing. The openings that are at first large gradually contract and 



140 A TEXT-BOOK OF GYNECOLOGY 

close. It is then difficult to say how large the opening may have been 
originally. The cicatrix that is formed is generally thin and firm. 
When the urine discharges freely from the bladder after the formation 
of a fistula, contraction of the bladder, with thickening of its walls, 




Fig. 58. — " The variety most commonly met with is the vesico- vaginal." — Eeed (p. 139). 

ensues. The urethra may be contracted on account of its inactivity. 
The vagina around the edges of a fistula is sometimes firmly fixed to 
the bone. In this way the edges of the fistula are drawn apart. Vesico- 
uterine fistula are rare. They can only be recognised after the uterine 
canal has been opened up. Uretero-vaginal fistula are situated in the 
fornix vaginae. They are small and admit only of the entrance of 
the point of a sound. They open at the point of a small papilla or else 
have very sharp edges. 

The etiology of urinary fistulae in general must take into account 
the element of pressure, the duration of which, rather than the in- 
tensity, determines the injury. Sometimes the surgeon produces a 
fistulous opening for the relief of chronic cystitis, or for the removal of 
a stone from the bladder, or the bladder may be accidentally wounded 
during the performance of the operation of hysterectomy. Ulcerations 
of the bladder may occasionally produce perforation of the septum, and 
are sometimes a consequence of the presence of a vesical calculus. A 
pelvic abscess may open in such a way as to give rise to a urinary fistula, 
which may be induced also by foreign bodies, such as the long-contin- 
ued use of a pessary in the vagina. Injury received during labour is 
generally looked upon as the most frequent cause of these fistulous open- 
ings. Such a condition may be produced by a tear through the septum, 
or, as is most commonly the case, a necrosis is produced by pressure dur- 



INJURIES OF THE EXTERNAL GENITAL ORGANS Ul 

ing tedious delivery. Whatever may cause a difficult labour, may, there- 
fore cause a fistulous opening between the urinary and the genital tracts. 
It is not necessary to dwell upon these conditions, as they are well 
known. Cuts that will give rise to fistulous openings may occasionally 
be produced by the use of instruments in accomplishing delivery. Such 
cuts usually occur in the lower part of the vagina. The forceps is 
no doubt more frequently blamed for the production of fistulous 
openings than it should be. It is generally used in difficult labours; 
that is to say, those in which there is long-continued pressure on 
the soft parts. We may conclude, therefore, that the fistulous open- 
ings are due to the long-continued pressure in such cases and not 
to the use of the forceps. They may be due to the nonapplication 
of the forceps. Fistulous openings have been produced, sometimes, 
as a consequence of cuts made by splinters of foetal bones during 
the performance of the operation of craniotomy. Malignant disease 
frequently causes fistulous openings, not only into the bladder, but 
also into the rectum. Xothing can be done by surgical means to alle- 
viate the sufferings of these poor unfortunates, and such cases need 
not be considered here. A calculus is frequently formed in the vagina 
as a consequence of the presence of a vesico-vaginal fistula. 

The symptoms of urinary fistula? in general demand careful consid- 
eration. When a patient complains of an involuntary flow of urine, 
an examination should always be instituted, to ascertain the reason 
why such an abnormal condition exists. After labour, the patient may 
be discharging the urine naturally, or she may be unable to pass it, 
and it may be retained in the bladder, and yet, within a few days, there 
may be an involuntary flow of urine due to the presence of a vesico- 
vaginal or one of the other forms of urinary fistulas. The pressure at the 
time of labour produces the necrosis, and the formation of the opening 
is delayed for several days until the slough separates. If the opening 
is caused by a tear, urine will flow at once per vaginam. 

The symptoms vary according to the situation of the fistulous open- 
ing. When situated high up, the bladder fills up to the level of the 
fistula, if the patient is in the erect posture, and there is no leak until 
the urine reaches so high as to overflow. When there is a urethro- 
vaginal fistula, the bladder may be able to hold the urine, and yet the 
urine will not come out through the normal opening. The patient's 
clothing in these cases is not kept wet. The odour produced from 
the urine becomes unpleasant to the patient and friends; the skin of 
the adjacent parts becomes excoriated, red, and irritated. Sterility is 
usually produced, although there have been cases of conception re- 
corded. The patient feels disagreeable to herself and to others. The 
general health frequently becomes considerably impaired, and the pa- 
tient is always ready to submit to operation if any promise of relief 
can be given. 

The diagnosis must be made between these fistulas and certain con- 
ditions of the bladder that allow the escape of urine. One of these 



142 A TEXT-BOOK OF GYNECOLOGY 

conditions is a paralysis of the sphincter vesicae muscle, due, fre- 
quently, to difficult labour, and rendering the patient unable to hold 
her water. It may remain in the bladder while the patient lies in the 
recumbent posture at night, but when she rises to the erect pos- 
ture it comes away and wets her clothing. The irritated appearance 
of the genitals, and the characteristic odour, indicate that there is 
a fistula. To be satisfied of this, it is a good plan to inject sterilized 
milk, or a coloured nonirritating fluid, into the bladder. Any fluid 
escaping from the bladder can then be more readily detected on ac- 
count of its colour. This method is one of the best in vogue. Some- 
times the opening can readily be detected with the finger. When the 
milk is being used, it is better to have the patient turned on her left 
side with the Sims speculum in position. All discharge must be wiped 
away from the vagina in order that the field to be inspected may be in 
a cleanly condition. As the bladder is distended, we must carefully 
watch the anterior vaginal wall for any oozing of the stained fluid. 
If no fluid comes away, we must infer that the opening is below the 
sphincter, or that no opening exists. If no special leak occurs during 
the act of micturition, we must then conclude that the leakage of urine 
is not due to the presence of a urinary fistula, but is due to some other 
cause. 

In considering the prognosis, it is well to bear in mind that small 
fistulaa sometimes heal without any surgical intervention. Many of the 
small fistulas, however, and all of the large ones, require operative 
treatment. The prognosis is not so favourable for cases in which the 
connective tissue of the urethro-vaginal and vesico-vaginal fold is 
bound down to the bony parts in the neighbourhood. If this condition 
is present, it is difficult to approximate the edges without great ten- 
sion being placed upon the stitches. 

Treatment. — Eecently formed fistulous openings have a tendency to 
close. This tendency is one of the difficulties met with in attempting 
to keep up free drainage from the bladder by means of an artificially 
produced vesico-vaginal fistula for the treatment of chronic cystitis. 
Such fistulous openings will often close if they are kept clean and 
anointed with a little vaseline or zinc ointment, and if the bladder is 
kept washed with boric acid or sodium biborate (3j to Oj) solution, to 
remove the incrustations that are liable to form at the edges of the 
fistula. Operations on such cases are difficult. We must be able to 
reach the fistulous openings, and we must be able, when we have reached 
them, to bring the edges carefully together with sutures. There are 
two positions in which the field of operation may be brought into view. 
One is the position on the left side with the Sims speculum, and the 
other position is that in which the patient is placed on the abdomen 
with the knees hanging over the end of a structure raised up in the 
centre of an operating table. To use the latter position, Eoss proceeds 
as follows: The head of the patient should be lower than the buttocks, 
and therefore different-sized boxes should be used, carefully padded and 



INJURIES OF THE EXTERNAL GENITAL ORGANS 143 

covered with pillows, placed upon the operating table, unless one is 
fortunate enough to obtain the use of a Bozeman's table. The patient's 
head is made comfortable, her arms are allowed to hang down on either 
side, parts under the chest and abdomen are carefully padded, a pillow 
is inserted under the crests of the ilium where they impinge upon the 
newly constructed platform, and great care is taken to see that the 
knees do not touch the table below. If the knees are allowed to press 
for any considerable time on the table while the patient is under an 
anaesthetic, sloughs may be produced that will be very tedious to heal. 
A rubber sheet is placed in such a way that the water that is being 
used in a constant stream from the " douche can " or " bag " is con- 
ducted to a foot bath at the end of the table. An assistant then stands 
on one side of the patient and holds the Sims speculum, or some modi- 
fication of the same, in position on the posterior vaginal wall. The 
operator may use the German water speculum for this purpose. It is 
not easy for the anaesthetist to give the anaesthetic while the patient is 
in this position unless the pillows are properly arranged. 

Sims pared the edges of the fistula in such a way as to avoid the 
mucous membrane of the bladder. He brought together the edges 
of the fistula with silver wire, without allowing the stitches to pene- 
trate the mucous membrane. Other operators have not done this, but 
have cut directly through, paring all tissues evenly, and bringing the 
edges evenly together with sutures passing through the mucous mem- 
brane, as well as through the vesico-vaginal tissues. Others use the flap- 
splitting method in order that they may be able to make use of the 
larger wound surface thus produced in the healing process. Any of 
the three methods will answer if certain important details are carried 
out. The approximation must be exact and thorough; the stitches must 
be inserted far enough away from the edges to enable them to give 
the proper amount of support; precautions must be taken to prevent any 
contamination of the wound by urine, or other septic material, and heal- 
ing by first intention must, if possible, be procured. 

Each case must be individually considered. If the rules that are 
well-known to govern the healing process in this locality are adhered to, 
success will follow; if these rules are not adhered to, success will not 
follow the operation, no matter which operator's method is employed. 
In every case of vesico-vaginal fistula it is advisable to examine for 
vesical calculus before closing the fistula. 

It is not wise to operate at too early a period after the formation 
of the fistula. The tissues must be allowed to contract to their utmost 
extent and to regain their natural condition after the softening that 
is produced as a result of pregnancy has disappeared. Unless this is 
done, they are too friable and too easily torn to stand the strain of 
stitches. It is not wise to attempt to operate for at least eight weeks 
after confinement, nor is it wise to do a second operation until at least 
a month or six weeks have elapsed since the first was performed. A 
preparatory treatment has been advocated by some for the purpose 



144 A TEXT-BOOK OF GYNECOLOGY 

of loosening cicatricial bands. This may be necessary. Incisions can 
be made and tissues loosened, and these incisions allowed to nnite 
before any fresh ones are made. We may thus gain considerable room. 

Frequent vaginal injections are not necessary in all cases, in order 
to bring the edges into good condition. Any irritation that is present 
in the vagina may be relieved by the use of pessaries made of fifteen 
grains of oxide of zinc to a hundred and twenty grains of cacao butter, 
introduced into the vagina once or twice a day. It is wise to heal up 
ulcerations about the buttock. 

Sims's Operation. — The bowels having been thoroughly evacuated 
by a cathartic and the rectum having been washed out by an enema 
immediately before the operation, the patient, having been shaved and 
sterilized, is placed upon a table on her left side in the Sims position 
(Fig. 2). The Sims duck-bill speculum is introduced into the vagina 
and intrusted to an assistant, who is instructed to hold it with consid- 
erable attention, exerting the force in an upward and forward direction. 
The fistula will then be brought to view. It should at this point be 
inspected carefully to determine its natural lines and the consequent 
direction in which the lips will be approximated. Having determined 
this point, the margin of the fistula is seized with a volsella or long 
hemostatic forceps and the continuous strip of cicatricial tissue is cut 
away from the margin of the fistula along its entire circumference, 
care being taken to avoid the vesical mucosa. The small amount of 
blood that oozes from this surface should now be carefully wiped away 
and the surface inspected. If at any point the surface is not deemed 
broad enough for the purpose of approximation and union, a little 
more tissue may be removed. Simon, who was very successful in deal- 
ing with this accident, included the vesical mucous membrane in the 
denudation; but Emmet avoided doing so on the ground that it caused 
unnecessary and often embarrassing hemorrhage. He alludes to a case 
in the practice of Peaslee in which the patient died from hemorrhage 
of this character. In some cases in which the vaginal wall was made 
too thin, it was the practice of Sims, Emmet, Bozeman, and the early 
operators in this field, to carry the denudation to the vaginal surface; 
or, if this was impracticable, to split the margins of the flap. It was 
in this incidental practice that these early operators gave recognition 
to an important principle of procedure, which many years later was 
published by Lawson Tait and adopted by his followers. The margins 
of the fistula having been thus incised, a short, strong, slightly curved 
needle, loaded with a double loop of silk thread and carrying silver wire, 
is passed through one lip of the fistula, and brought over and out 
through the other lip at a directly opposite point. One after another of 
these sutures is passed at intervals of from an eighth to three sixteenths 
of an inch apart. When the silver wires are all in situ, the margins are 
again washed carefully and the sutures, one after another, are closed by 
simply bringing the opposite ends together and twisting them. Great 
care should be exercised in this manipulation, as by overdoing it the 



INJURIES OF THE EXTERNAL GENITAL ORGANS 



145 



•entire operation may be easily defeated. It is important to cross the 
wires first and ascertain exactly the point at which they will cross. 
Each end should be bent by a sharp angle at that point, crossing and 
twisting thence outward. If they are crossed without any regard to this 
precaution, the twisting will extend toward the field of operation 
and toward the distal layer of the wall. In this way a destructive 
tension will be brought to bear upon the tissues, the wire will cut out 
before union is completed, and the objects of the operation will be 
defeated. Silkworm gut may be employed as a suture material, 
although it is probable that if the technique of Sims is to be followed, 
it would be better to follow it in its entirety. The operation thus con- 
cluded, the vagina is again thoroughly irrigated and a little gauze is 
inserted. The sigmoid catheter with several feet of small drainage 
tubing attached is inserted into the urethra and the patient is put 
to bed. 

Ross's Operation. — The instruments required for the operation are 
as follows: 



Sims's speculum, or some modification of | 
Sims's, such as Simon's, Fritsch's, the 
self-retaining, or the German water 
speculum. 

Retractors or spatulae. 

Three or four single-toothed, double- 
bladed tenacula. 

Douche can and tube. 

Pressure forceps. 

Long-handled dissecting forceps. 

Several other long-handled tissue forceps 

Small bistouries, or a set of Sims's vesico- 
vaginal fistula blades. 



Angular-curved and flat-curved scissors. 

Small sponges or wipes. 

Sponge holder. 

Curved needles, short, but curved almost 

into an oval instead of into a circle, 

with cutting sides. 
Needle holder. 
Silver wire, best quality. 
Catgut. 
Silkworm gut. 
Wire twister. 
Blunt hook. 
Large-sized male sound. 



In a good light, with the patient in a position on the face and 
properly placed, the operator standing up to his work, the water specu- 
lum holding the posterior vaginal wall and allowing water to constantly 
trickle over the fistulous opening, this operation is rendered an easy 
one. It may be performed without an anaesthetic and with perfect 
success. It is the getting at the part that is the most difficult portion 
of the operation. After the parts have been reached by sight and by 
touch it is then an easy matter to pass the sutures. 

Any sponges that may be used must be small. If a current of water 
is allowed to trickle continuously, it is scarcely necessary to use sponges. 
When we are ready to pare the wound, a tenaculum should grasp each 
side of the fistulous opening, taking in all the structures. The tenacu- 
lum should be one that will lock, so that it can hang in position with- 
out requiring the attention of a hand. A sound is passed into the blad- 
der to push out the wall during the paring of the edges of the fistula. 
Then, either a knife is passed directly through the edges of the wound, 
in order that a portion may be completely pared off, or a pair of 
11 



146 A TEXT-BOOK OF GYNECOLOGY 

sharp-pointed scissors is inserted and is run round the edges as the 
first step in the flap-splitting process. Some operators cut down on 
the vaginal side away from the edge of the fistula, as far as halfway 
through the thickness of the vesico-vaginal septum, and then turn in 
toward the bladder the two flaps thus removed, so that the bladder con- 
tains a small portion of vaginal mucous membrane lined with squamous 
epithelium. The outside raw surface is then drawn together by sutures. 
Hemorrhage should be checked by means of the hot douche. Any large 
bleeding points found should be compressed with pressure forceps. 
This should be done before the edges are brought together, though it. 
is not wise to lose much time if general oozing continues, as the pres- 
sure of the sutures will usually stop this. The greatest amount of 
oozing usually takes place from the congested mucous membrane lining 
the bladder. The edges must now be carefully adapted with sutures. 
When the sutures are passed, great care must be taken not to include 
much, if any, of the mucous membrane of the bladder. A blunt hook 
is used to make counter pressure during the introduction of the sutures. 
It is not very frequently needed. The sutures should be passed close 
enough together to afford ample support. 

If silver sutures are used, iodoform gauze should be inserted into the 
vagina, to prevent the suture ends from irritating the posterior vaginal 
wall. Care must be taken, in removing this gauze, not to use any force 
that is liable to disturb the stitches, should a portion of it become 
entangled in the meshes of the wire. 

With reference to the original operation of Sims, there are several 
points that are open to criticism, notwithstanding the fact that he and 
his immediate followers achieved great success in their operations upon 
this class of cases. The experience of the profession, however, has 
demonstrated that a modification of the technique will result in greater 
facility of operation, and in at least equally satisfactory results. Thus 
the Sims operation requires the presence of an assistant to hold the 
speculum. When the perineum is retracted and the atmospheric pres- 
sure is exercised upon the anterior vaginal wall, the fistula drops inward 
and forward — the farthest possible distance away from the operator. 
It is necessary for him, therefore, to employ long-shanked instruments 
to conduct his operation. The method of denudation is one which 
necessarily sacrifices a greater or lesser amount of tissue from a locality 
where too much tissue has already been destroyed. In the event of 
successive operations by this method, the hope of a successful issue is 
ultimately destroyed by the sacrifice of the septum. Eeed remembers 
to have seen a case in the Eotunda Hospital, in Dublin, in which 
the entire base of the bladder had been whittled away in successive 
efforts to close an originally large fistula. As an example of what some 
operators recognise as an easier and equally effective technique the 
following is given: 

Reed's Operation. — The patient is prepared precisely as indicated 
in the preceding paragraphs. She is placed on the table on her back,. 



INJURIES OF THE EXTERNAL GENITAL ORGANS 



147 



with, her knees drawn well up, and retained in that position. Mechan- 
ical devices are better, however, as injury to the hip joint has been done 
by the unguarded action of assistants in exercising too much pressure 
upon the legs. A Jones's self-retaining speculum is now inserted, by 
which means the fistula is brought directly into view. The line of 
closure having been determined, an incision is made outward from 
either angle, extending 
through the mucous 
membrane of the vagina. 
The margin of the fistula 
is now split, either by 
means of the knife or a 
pair of sharp-pointed scis- 
sors curved on the flat, 
and one blade inserted 
through the incision al- 
ready made beneath the 
mucous membrane, and 
carried around to the in- 
cision in the opposite an- 
gle (Fig. 59). The other 
lip of the fistula is treat- 
ed in the same way. The 
mucous membrane of the 
vagina and of the bladder 
are by this means sepa- 
rated into two flaps; those 
in the bladder can be 
folded inward and ap- 
proximated, while those 
within the vagina can be 
folded outward and simi- 
larly approximated. A 
curved needle mounted 
on a handle and specially 
devised for the purpose, 
is now inserted just be- 
neath the vaginal mu- 
cous membrane, made to 

dip deeply into the cellular layer, and brought out just beneath the 
vesical mucosa. It is then crossed over and inserted beneath the 
vesical mucosa; dipped deeply into the cellular layer, and brought 
out just beneath the vaginal mucosa. It is then threaded with 
silkworm gut and withdrawn. Other sutures passed in a similar 
way at intervals of less than a quarter of an inch (Fig. 60) are 
then drawn together and tied. In this way, the approximation 
surfaces are increased in area (Fig. 61) while by the old through-and- 




Fig. 59.—" The margin of the fistula is now split." — 
Reed. 



148 



A TEXT-BOOK OF GYNECOLOGY 



through sutures they are diminished in area (Fig. 62). The sutures 



are removed on the eighth or tenth 




Fig. 60. — " Other sutures are passed in a similar 
way at intervals of less than a quarter of an 
inch." — Keed (page 147). 



day. The buried suture may 
be employed somewhat after 
the manner introduced by 
Martin, of Berlin. After the 
denudation has been made, 
just as in the operation by 
means of the interrupted su- 
ture, formalinized catgut is in- 
serted so as to include all of 
the cellular structure between 
the two mucous layers. A con- 
tinuous suture is employed for 
this purpose, involving the cel- 
lular tissue, but not passing 
through either mucous layer 
(Fig. 63), as generally tied, 
and the superficial intermucous 
suture is then adjusted. The 
advantage of this form of clos- 
ure is that the approximation 
is very effective and no trouble 
arises from the removal of 
sutures. 

After-treatment. — Some op- 
erators do not use the semi- 
prone position and the self- 
but this treatment is the best 



retaining catheter after operation; 

that can be pursued and is adopted by many. 

If it is intended to 
place a catheter in the 
bladder the best form 
to use is Skene's modi- 
fication of Bozeman's 
self - retaining hard- 
rubber catheter. There 
is another form of 
winged soft - rubber 
catheter that can be 
used. The urine is 
then collected in a 
vessel placed in bed. 
The catheter should 
be changed every day, 
as the salts of the 
urine are deposited on the perforations, and in this way the instrument 
is very soon blocked up. The instrument also requires cleansing, but it 




Fig. 



61.—" In this way the approximation surfaces are in- 
creased in area." — Keed (page 147). 



INJURIES OF THE EXTERNAL GENITAL ORGANS 



149 




can be replaced in the bladder a few minutes after its removal. It is 
better to have two catheters, so that when one is removed for the pur- 
pose of cleansing, the other can be placed in position. The nnrses must 
be vigilant, and immediately report any plugging of the catheter to the 
proper authority. Some prefer to 
use the catheter for two or three 
days only, and then to have the 
urine drawn every three hours. 
Tsokana, of Athens, Greece, re- 
ports, in a communication to the 
editor, that he closes the fistula 
with interrupted silkworm gut su- 
tures, tied by a single knot with 
an extra whirl, and permits his 
patients to get up and go about 
shortly after the operation is com- 
pleted. His results are satisfactory, as he claims that the upright pos- 
ture favours the natural drainage of the bladder and the retention of 
the parts in a state of approximation. 

The after-clangers of the operation are irritation and inflammation 
of, and hemorrhage into, the bladder. When blood clots collect they 






Fig. 62. — " By the old through-and-through 
sutures the approximation surfaces are di- 
minished in area." — Keed. 











fflfif**'' r - ^*^^fcfc 


" 




■ 1 O^ 


^^i"^ : 


Bl\'.>il| A 

. v 


----- V ' t 

V'' "-" ZsL/ JSJafSZ 




N<^ //^_i 


WM ' / / /^' 


mm 



Fig. 



A continuous suture is employed for this purpose, involving the cellular tissue, 
but not passing through either mucous layer.'' — Keed. 



are troublesome. If the hemorrhage is severe, the fistulous opening 
must be reopened. This should not be necessary if proper attention 
to details is given at the time of operation. It is always possible 



150 A TEXT-BOOK OF GYNECOLOGY 

that a hemorrhage may occur, subsequently to operation, in a patient 
prone to bleed, but all excessive hemorrhage should be checked at 
the time of operation before the stitches have been finally tied. If 
secondary hemorrhage occurs from the third to the fifth day, a vaginal 
tampon may relieve it. The ureter has been caught in a stitch on more 
than one occasion. If the patient surfers from intense pain in the 
neighbourhood of the kidney after the performance of this operation, 
one should suspect that some such unfortunate occurrence has taken 
place. Symptoms of uremic poisoning may set in as a consequence of 
this accident. The sutures are usually removed from the seventh to the 
tenth day. Great care must be taken in removing these sutures. If 
silver wire is used, the portion of the loop away from the knot should 
be bent outward, so that the loop then has about the curve of one of the 
needles used in placing the sutures. Counter pressure should be placed 
over the parts while the stitches are being withdrawn. Sutures must be 
counted and must be all removed, because a loop of wire left behind 
may afterward become the nucleus of a vesical calculus. The catheters 
placed in the bladder should be kept in situ, except when they are re- 
moved for cleansing purposes, until the operator feels satisfied that 
the patient can pass water voluntarily without breaking down the 
wound. This will depend, to a great extent, upon the appearance of 
the wound. In some cases, it is possible to let the patient void urine 
earlier than in others. The smaller the fistulous opening, the earlier 
the patient may be allowed to void urine; the larger the opening, the 
longer this act should be delayed. If there is no great amount of vis- 
ceral irritation, Eoss leaves the self-retaining catheter in situ until 
after the stitches have been removed, and keeps the patient turned on 
her face for at least a week after the performance of the operation. 

When the operation has not been an entire success, a second, a 
third, or even a fourth must be performed. At each operation a 
portion of the fistulous opening closes and the fistula becomes smaller. 
One must not be discouraged. Each operation should bring us nearer 
the long-looked-for goal. 

It sometimes happens after these operations that, when the fistulous 
opening is closed, the patient continues to lose urine involuntarily and 
does not believe in her recovery. In such cases there has been a loss 
of tone in the sphincter vesicae muscle, but in others the parts gradually 
regain their tone. 

Atresia of the Upper Part of the Urethra is sometimes found in cases 
in which a vesico-vaginal fistula exists. It will then be necessary to 
make a new opening, and to keep it open by the use of sounds, unless the 
operator feels disposed to cut out a portion of the urethra and unite 
the neck of the bladder to the portion of the urethra below the excision. 
If atresia exists between a urethral fistula below and a vesico-vaginal 
fistula above, the readiest way to deal with it is to thoroughly loosen up 
the tissues and bring the upper edge of the vesical fistula down to the 
outer edge of the urethral fistula. To unite such a fistula, however, a 



INJURIES OF THE EXTERNAL GENITAL ORGANS 



151 



•combination of the transverse and longitudinal operation may be done. 
A transverse incision may be made by making an artificial vesicovagi- 
nal fistula just above the neck of the bladder. The upper edge of this 
can then be stitched to the lower edge of the urethral fistula, and, after 
healing has taken place, the edges of the original vesico-vaginal fistula 
can be closed by stitches placed so as to bring the edges together from 
.side to side, leaving a longitudinal scar. 

Uretero-vaginal Fistula. — A fistula may readily be formed between 
the ureter and the uterus, or between the ureter and the vagina. Such 
fistula? are fortunately rarely met with. They are very difficult to deal 
with and at times somewhat difficult to discover. These fistula? can 
be most readily discovered by means of a probe. If the probe passes 
on farther than the confines of the bladder would indicate, it must 
be disappearing into the ureter toward the kidney on that side. AVe 
can make out the pervi- 
ousness of the lower por- 
tion of the ureter by in- 
troducing a probe in the 
other direction toward 
the bladder. 

T rcatment . — Ne- 
phrectomy may be con- 
sidered but should only be 
carried out as a last re- 
source. If the fistula can 
be closed by a direct 
method of operation, this 
should be carried out. If 
it can not be closed, we 
must then contemplate 
implantation of the ureter 
in the bladder. 

To effect closure of the 
fistula, an incision may be 
made down over the ureter 
and a catheter passed 
into the bladder, and out 
through an artificial open- 
ing made in the bladder 
wall just below the ure- 
teral fistula. The cathe- 
ter can then be carried on 
up into the ureter and the tissues around closed by silver-wire sutures. 
Another catheter may be placed in the bladder alongside of this one in 
order that it may be kept empty. The flap-splitting method may be here 
applied, as in vesico-vaginal fistula operations. (For the operation of 
implantation of the ureter in the bladder see Uretero-cystostomy.) 




Fig. 64.— "Recto-vaginal fistula.*"— Mayo Eobsox (p. 152). 



152 



A TEXT-BOOK OF GYNECOLOGY 



Recto-vaginal Fistula. — Recto-vaginal fistula is by far the most fre- 
quent of the fistula between the intestinal and vaginal tracts, and may 
occur at any part of the posterior vaginal wall (Fig. 64). It is a pecul- 
iarly distressing ailment, not only because of fasces escaping by the 
vagina, but from the fact that intestinal gases pass into the vagina and 
escape with an audible bubbling or hissing noise; and the odour being 
perceptible to the sufferer, she broods over her condition, secludes her- 
self from society, and usually passes a miserable existence, which may 
end in melancholia. 

Causes. — Cancer, syphilis (see Malignant Neoplasms of the Va- 
gina; also Syphilis), and injury are the usual causes. Pyosalpinx 
and other inflammatory diseases of the appendages not infrequently 
cause fistulas, but these are usually rectal or vaginal, seldom recto- 
vaginal. 

Fistula from Traumatism.— -Recto-vaginal fistula may occur from 
the ulceration induced by the long-continued presence of a pessary, 

from the presence of some 
foreign body in the vagina or 
rectum, or from a stab wound 
accidental or intentional. In 
these cases, the fistula usually 
heals on removal of the cause,, 
together with careful attention 
to the wound by mild antisep- 
tic douches and gauze packing. 
Sometimes, stretching the 
sphincter so as to temporarily 
paralyze it gives rest to the 
parts and assists the healing 
process. 

Injuries occurring in child- 
birth leading to recto-vaginal 
fistula are not so infrequent as 
modern obstetric treatment 
might lead one to suppose. 
They not infrequently follow 
complete rupture of the peri- 
neum, where the rent has 
passed well up the recto-vag- 
inal septum, and where the 
primary operation has led to 
healing of the perineum and 
perhaps of the sphincter, but 
where there has been a failure 
in union of the rectal wound. 
These fistulas may occur at any part on the posterior wall of the rec- 
tum, from just within the sphincter up to the highest point the finger 




Fig. 65. — " Lay the whole fistula open by cutting 
through the tissues intervening between it 
and the surface."— Mayo Eobson (page 154). 



INJURIES OF THE EXTERNAL GENITAL ORGANS 



153 



can reach, and may vary in size from an opening admitting a Xo. 1 
catheter to a slit admitting one, two, or three fingers. 

They may also follow on sloughing caused by pressure from delayed 
delivery, but from this cause recto-vaginal is much less common than 
vesico-vaginal fistula. 

Small fistula? will occasionally heal spontaneously; others require 
surgical intervention. If the fistula is situated high up in the vaginal 
canal and fails to close 
under cleanliness and 
general attention to the 
bowels, a plastic operation 
will be advisable. 

The bowels should be 
well cleared by aperients 
given for three or four 
days before operation, 
and during this time the 
vagina should be douched 
night and morning with 
some nonpoisonous anti- 
septic solution, such as 
salufer or izal. 

Mayo Robson's Opera- 
tion. — With the patient 
in the lithotrity position, 
or on the left side, and 
the perineum drawn back 
by a retractor, so as to ex- 
pose the fistula, the edges 
of the opening are pared 
by a narrow sharp knife 
or by means of small 
curved scissors. The rec- 
to-vaginal septum is then 
split by a blunt dissector 
for a quarter or half an 
inch round the fistula, so 

as to make a broad raw surface without material loss of tissue, and so 
as to be able to bring together the rectal part and the vaginal part by 
separate sutures. 

Catgut sutures are first applied to the rectal edge of the fistula by 
means of a rectangular cleft-palate needle, the sutures taking up the 
submucous tissue close to, but not including, the mucous membrane, 
and being placed sufficiently close to occlude the rectal opening. These 
sutures, being applied from the vaginal surface, are tied, cut off short, 
and buried by the next row of sutures, which may be of chromicized 
catgut or of silk or silkworm gut. If catgut is employed, the stitches 




Fig. 66. — " Sutures are inserted in the margins of the 
vaginal mucous membrane and in the margins of 
the rectal mucous membrane." — Mayo Robsox 
(page 154». 



154 



A TEXT-BOOK OF GYNECOLOGY 



may be buried; if silk or silkworm gut is used, the sutures must be 
tied on the vaginal surface and removed in about ten days. If the 
vagina is contracted, it may be found easier to repair the rectal edges 
of the fistula? from the bowel surface, using a Sims speculum through 
the well-stretched anus. 

After operation the bowels need not be disturbed for a week, and 
then an olive-oil injection will, as a rule, answer all requirements. 

A boric acid or izal vaginal douche should be used night and morn- 
ing. The employment of a catheter is, as a rule, neither necessary nor 
advisable. The patient may be allowed to use the sofa at the end of a 
fortnight. 

If the fistula is fairly low, say within an inch of the anus, Mayo 
Eobson finds it best to lay the whole fistula open by cutting through the, 
tissues (including the perineum or its remains) intervening between 
it and the surface (Fig. 65). This he does by one sweep of a probe- 
pointed bistoury or by 
means of scissors, the va- 
gina being thus made 
continuous with the rec- 
tum by a slit instead of a 
fistula. The assistants or 
nurses, standing one on 
each side, place a hand 
on the skin over each 
tuber ischii and retract 
gently, converting the H- 
shaped gap into a trans- 
verse wound, as shown in 
the illustration; pointed 
scissors are then employed 
to open up the recto- 
vaginal septum so as to 
convert the narrow edge 
into a raw surface; slits 
are then made on each 
side straight forward for 
about an inch, as in 
Tait's operation for peri- 
neorrhaphy. The angles 
being drawn forward by 
catch forceps, chromi- 
cized catgut sutures are 
inserted in the margins of 
the vaginal mucous mem- 
brane, so as to approximate them and thus form the vaginal floor by 
closing the V-shaped slit; and in the same way chromicized catgut 
sutures are inserted in the margins of the rectal mucous membrane, so 




Fig. 67. — " We now have a large rectangular raw sur- 
face." — Mayo Eobson (page 155). 



INJURIES OF THE EXTERNAL GENITAL ORGANS 



155 



as to form the anterior rectal wall by closing the V-shaped slit in the 
rectum (Fig. 66); these sutures are cut off short. "We now have a large 
rectangular raw surface, which can be rapidly closed by four or six 
silkworm-gut sutures entering on one side at the skin margin, aud 
emerging on the other at the same spot as in the well-known and 
extremely valuable perineorrhaphy operation referred to (Fig. 67). 

Before drawing tight the last series of sutures, the wound is bathed 
with a l-in-2,000 solution of perchloride of mercury. ~No vessels are 
ligatured. When the final sutures are tied the parts look perfectly nor- 
mal and no raw surface can be seen. The bowels are moved daily after 
the second day by a plain water enema, and the vagina is washed out 
daily with boric lotion. 

No catheter is employed if it can be avoided, and, as a rule, its use 
is not necessary. 

The parts are dressed with iodoform gauze, over which wool and a 
T-bandage are applied. The sutures are removed about the tenth day 
and the patient is allowed to be up about the fourteenth. 

Mayo Eobson says that he can with the utmost confidence recom- 
mend the operation as a most satisfactory and expeditious method of 
treating the class of cases under consideration. 



CHAPTER XV 
INJURIES OF THE EXTERNAL GENITAL ORGANS (Continued) 

Rape— Objective evidences: A. Local conditions; laceration of the hymen, vulva, 
hemorrhage, evidence of recent injury, venereal infection, laceration of the 
vagina, etc. , pregnancy ; B. Injuries on other parts; C. Condition of clothing — 
Schedule for examination— Indecent assault— Prolapse— Injuries to the peri- 
neum and vagina — Uterus. 

Rape. — Medico-legal questions in relation to the female generative 
organs chiefly have reference to — 

1. Pregnancy. 

2. Parturition. 

3. Sterility. 

4. Venereal disease. 

5. Rape. 

6. Indecent assault. 

7. Damage claims after injury. 

8. Malpractice suits. 

Rape is defined as the carnal knowledge of a female without or 
against her consent. In most courts vulvar, not vaginal, penetration 
has to be proved, a circumstance very disadvantageous to the defence. 

In cases of rape, the gynecological specialist is rarely the first to 
examine the victim, who has usually passed through the hands of a 
police surgeon or the family physician, or both. If a gynecologist is con- 
sulted at all, it is usually when the case comes into court, or at a time 
when the characteristic appearances may no longer be present. It would 
be greatly in the interests of justice to have a regulation enforcing the 
co-operation of an experienced gynecologist at the very outset in every 
case. The significance even of the typical lesions is by no means easy 
to estimate, and the examinations, especially in the case of young chil- 
dren, often present unusual difficulty. 

The objective evidences of rape are: (a) Local injuries to the geni- 
tals; (b) injuries elsewhere, due to a struggle, or possibly to sadism; (c) 
signs of seminal or blood stains on the clothing, tearing, etc. As the 
subjective evidence mainly rests on the uncorroborated testimony of 
the victim, the medical examination should include matters which 
indirectly corroborate or contradict her statements. There ' is no 
crime which becomes oftener the subject of groundless charges made 
156 



INJURIES OF THE EXTERNAL GENITAL ORGANS 



157 



for purposes of blackmail or revenge. We will consider here those 
points which call specially for observation from the gynecological point 
of view. 

A. Local Conditions. — These are only characteristic in the case of 
virgins or where unusual force has been exerted. The most important 
are: (1) Laceration of the hymen, (2) contusions or abrasions of the 
vulva, (3) hemorrhage, (4) evidence of recent injury, (5) venereal 
infection (gonorrhoea or syphilis), (6) in rare cases, lacerations of the 
vagina, perineum, rectum, or bladder may result where there is great 
disproportion between the male and female organs, (7) pregnancy 
may also occur. 

1. Laceration of the Hymen. — The principal source of error lies in 
mistaking for lacerations congenital notches or defects. The appear- 
ance and variety of these are well depicted in photographs in E. V. 
Hofmann's Hand Atlas of Legal Medicine. 

The variety of forms which these conditions may assume is remark- 
able, and the general profession is very little informed about them. 
The most important form is the fringed or serrated hymen. On the 
one hand, one of these conditions may give the impression of lacera- 
tion, and on the other it is often evident that intromission could 
take place without rupturing it. There is also the danger of con- 
fusing ulcers with lacerations, or of mistaking old lacerations for 
recent ones. The examination should be made most carefully with 
the aid of an assistant and in a good light, the finger being passed 
round behind the hymen so as to bring it into relief. Whitish 
scars denote lesions previously existing. Granulating wounds and 
erosi'ons show that the injuries have existed several days, and prob- 
ably a week, if they are in process of healing. The recent defloration of 
the virgin hymen is usually accompanied with a considerable amount of 
swelling, redness, and pain. Intromission and ejaculation may, how- 
ever, occur without rupture of the hymen, and, owing to the increased 
frequency of local gynecological treatment in young unmarried women, 
the hymen is liable to have been previously interfered with. A typical 
ruptured hymen is the exception rather than the rule in most cases of 
rape. 

Full objective proof is only forthcoming in a small proportion of all 
cases. The relative proportion of the genital organs in the victim and 
the accused must be considered in order to give a definite answer in 
individual cases. 

During the healing stage there is little that is characteristic in the 
lesions. 

2. Vulva. — The contusions about the vulva should be associated 
with ecchymosis and persist for a week or ten days. 

3. Hemorrhage. — The preservation of blood-stained undergarments, 
etc., is more important. Their destruction, or washing by the victim's 
family, may destroy an important proof. 

4. If anatomical evidence of recent injury of the genitals is discov- 



158 A TEXT-BOOK OP GYNECOLOGY 

ered, it will usually be accepted as positive proof of penetration. Ab- 
sence of anatomical evidence does not, however, exclude penetration. 

5. Venereal Infection. — The presence of acute gonorrheal discharge 
in the victim makes it most important to see if that condition exists in 
the accused. The diagnosis should always be confirmed by bacteriologic 
methods. 

It is much less easy to recognise gonococci in the female than in 
the male secretions, owing to the constant presence of other diplococci. 
Examinations of stains upon linen, etc., for gonococci rarely give 
trustworthy results, owing to the numerous sources of possible error. 

After a first coitus a slight discharge may persist for a few days, 
and want of cleanliness may in itself cause a discharge. Eepeated visits 
will be necessary in order to observe the course of the case. 

Syphilis. — Hard and soft chancres are occasionally met with in 
connection with rape. The most important point here is a careful in- 
vestigation of the date of onset as compared with the date of the 
assault, and the exclusion of lesions elsewhere. Eepeated visits are 
usually necessary. It must also be shown that the accused was in a 
condition to communicate the disease. 

6. Severe injuries, such as rupture or laceration of the vagina, rectum, 
bladder, or perineum, are rare, and occasionally they are fatal. They 
are most liable to occur when a number of men violate the same victim 
in succession. In the Oriental child-marriage such injuries are fairly 
frequent. 

7. Pregnancy. — The correspondence of conception with the time of 
the alleged coitus is naturally the chief point to establish. 

B. Injuries on other parts should be carefully searched for, espe- 
cially finger prints, scratches and bruises of the abdomen, pubes, and 
thighs, as well as of the chest, limbs, and face, with or without tearing 
of the clothing. The absence of these tends to throw doubt upon the 
allegations of rape, unless there was more than one assailant, or the 
use of narcotics, intoxicants, or anaesthetics is alleged. The vexed ques- 
tion of the possibility of rape during natural sleep has little practical 
bearing upon the ordinary class of cases. Surprise and terror may, of 
course, lessen the power of resistance. Conditions suggestive of sadism 
should lead to a very careful examination into the mental state of the 
accused. 

C. Condition of the Clothing, etc. — Seminal stains. — Besides ex- 
amining the clothing for signs of tearing, any stains looking like semen 
or blood should be carefully preserved and submitted to expert examina- 
tion. The well-known straight outlined stiffening of the stains is strik- 
ing. The skin of the abdomen and thigh should be searched for traces 
of the seminal crust. In the case of seminal stains the Florence reac- 
tion is invaluable as a prompt preliminary test. A drop of the Florence 
solution (composed of iodine, 2.5 parts; potassium iodide, 1.5 parts; and 
water, 30 parts) is brought into contact with moistened filaments 
from fabrics containing semen observed beneath the microscope. An 



INJURIES OF THE EXTERNAL GENITAL ORGANS 159 

abundant formation of fine brown needle-shaped crystals instantly oc- 
curs. The sensitiveness is decidedly lessened in the presence of urine, 
and is greater in cold than warm solutions. If positive results are thus 
obtained, spermatozoa should be searched for cautiously by moistening 
the fabric by imbibition, scraping the surface, and dissociating the 
fibres. The best results are obtained by making a culture film or cover- 
glass preparation and staining with the eosin and methyl green, which 
gives a double staining of the head of the spermatozoa. The specimen 
may then be mounted in balsam and examined under a one-twelfth-inch 
immersion lens. Unstained specimens examined with the ordinary 
dry lenses are much less characteristic. 

Spermatozoa are less numerous in old stains, but age does not impair 
the Florence reaction. To preserve suspicious stains, cut out the sus- 
pected portion of the material and place it between flat pieces of card- 
board during transmission to the laboratory. The fallacies of the 
Florence reaction as a final test are that lecithin and certain decompo- 
sition products give similar precipitates, but this in no wise impairs its 
utility as a preliminary test. Failure to give the reaction does not prove 
the stain to be nonseminal, but makes it unlikely that positive micro- 
scopic results will be obtained. 

The possibility of azoospermia must be borne in mind. 

Stains from vaginal or nasal mucus or pus can sometimes be recog- 
nised microscopically by the cellular element. 

Local lesions produced during rape are, as a rule, trivial, unless gon- 
orrhoea, soft chancre, or syphilitic infections occur. Occasionally vul- 
var abscesses or thrombosis have occurred. Among the rare conse- 
quences, gangrene is mentioned, but the few recorded cases of this seem 
to have been really noma of the vulva, occurring independently and 
wrongly attributed to violence. 

An examination of the assailant should be made as early as possible 
for signs of scratching or bruises, indicating attempts at defence by the 
victim, as well as for signs of recent coitus, seminal stains, or blood upon 
the shirt or drawers. The general state of muscular power should be 
noted and compared with that of the victim; the hands and nails 
examined with special thoroughness, if scratches exist upon the victim. 
An inquiry into the mental condition of the accused as to sanity, 
responsibility, and unnatural sexual instincts, should be made in 
every case. 

The following schedule by Lacassagne will serve as a guide, when in- 
vestigating a case, to guard against the possible danger of overlook- 
ing important points. 

Lacassagne's schedule for medico-legal examination of a case of rape 
or indecent assault. Name, age, address. Date, day, and hour of visit. 

Preliminary inquiry; statements about occurrence (let children 
talk). Examination to be made early; perineal coitus and digital at- 
tempts kept in mind. Remember frequency of simulation and false 
accusations. 



160 A TEXT-BOOK OF GYNECOLOGY 

A. Examination of Victim. — C4eneral condition — scrofulous, lym- 
phatic. Local condition (examine on table or couch in a good light). 
Condition of thighs and abdomen — scratches, bruises, and nail marks. 
Labia majora and minora, clitoris for redness, excoriation, ecchymosis, 
ulcers. Vestibule and vagina (open and close thighs to squeeze out 
liquids). Hymen — position, form, margin, orifice, folds; defloration by 
penis, finger, or foreign body (assistant to draw forward labium on one 
side while expert does the same). Discharge — physical character, 
amount; microscopic, examine for semen and gonococci. Signs of mas- 
turbation — elongated lesser labia, large turgescent clitoris, dilated 
vagina, pigmentation, precocious puberty about vulva, hair, and 
breasts. Examination of anus and perineum. 

Suspicious stains on body or clothing, especially chemise or drawers. 
Place under seal, noting date. Examine by Florence reaction and for 
spermatozoa; also for evidence of other origin of stain. Absence of 
spermatozoa not final. 

B. Examination of Accused. — Physical condition, strength, cuta- 
neous diseases. Clothing torn. Injuries, showing resistance. Sexual 
organs — size and appearance. Peculiarities, tattooing, hernia truss. 
Stains of blood or semen about person or clothing. Urethral discharge 
(look for semen if seen very promptly). Chronic purulent discharge. 
Alleged impotence. Mental condition as to sanity or full responsi- 
bility. 

Conclusions. — A. (1) Has the person been the victim of rape or sex- 
ual assault? (2) How has the assault been made? (3) Has there been 
perineal coitus or intromission of the penis or finger? (4) Is there red- 
ness, contusion, or laceration of the parts or defloration? (5) Has any 
•disease been communicated? Is such disease syphilitic? (6) It will be 
necessary to re-examine in days to note progress of wound. 

B. (1) Does accused show traces of recent or old venereal disease? 
(2) Is such disease of same nature as that found on victim? (3) Are 
there traces of a struggle or of suspicious stains? (4) Is accused sub- 
ject to bodily infirmity making coitus impossible? (5) Is his mental 
■condition normal or otherwise? 

Indecent Assault. — In a large proportion of cases the victim is usu- 
ally a little girl under ten years. The attempt is most often made with 
the finger. As a rule, the signs of a struggle are absent, and on this 
account the establishment of direct proof is often impossible. The 
local evidences are usually slight inflammation and reddening with or 
without laceration of the hymen. A slight discharge often follows. 
The method of examination is the same as in cases of rape. 

In such cases care must be taken to exclude local conditions, which 
frequently cause spontaneous vulvo-vaginitis in children. The pres- 
ence of the gonococcus is significant, but the possibility of infection 
from other children or from members of the family must be borne in 
mind. 

Evidences of masturbation, such as an elongated or turgescent cli- 



INJURIES OF THE EXTERNAL GENITAL ORGANS 161 

toris with pigmented labia, should be looked for. The pigmentation is 
usually unilateral. It must be borne in mind that children are naturally 
mendacious, and may either originate a story of assault themselves, 
or accept one suggested to them by their parents, or by leading ques- 
tions put to them by their parents, or by leading questions put to them 
in the course of the medical examination. 

Founder's classical advice to medical men charged with the inves- 
tigation of these cases, that one should close his ears and open his eyes, 
is to be kept constantly in mind. Another excellent rule is to refuse 
to give a medical certificate to be used by the friends of the plaintiff as 
the basis of the case. 

The civil consequences of injuries to the female genital organs have 
been but little studied or described. C. Thiem was the first to sys- 
tematize and collate our knowledge on the subject, and since then a 
fair number of observations have been recorded. 

The disabilities resulting from injuries may be classified as follows: 

Gynecological effects of injury in relation to disability and claims 
for damage. 

The effects of accident and injury upon the female genital organs 
may be classified as follows : 

1. Malposition of uterus due to accident. 

2. Injury to perineum and vagina. 

3. Injury to vulva. 

4. Injury to uterus. 

5. Injury to uterine appendages. 

Occasionally the injury may be the sole cause. More often it may 
act by aggravating existing disease. It is important to remember that 
the condition must be shown to arise from a single act of traumatism 
or overexertion, to be considered as the effect of accident. 

There is no evidence to show that retroversion of the nonpregnant 
uterus, or that anteversion, or anteflexion, or retroflexion, is ever 
primarily a result of accident in healthy persons. 

Any of the above malpositions, if already existing, may be, however, 
aggravated by falls, or contusions of the pelvic region. 

Prolapse. — A number of cases are reported by Thiem and others 
where prolapse has followed accidental straining and heavy lifting. 
The proof needed to establish this, is sudden and painful onset with 
swelling, oedema, and tendency to inflammation of the prolapsed parts. 
This should immediately follow the alleged accident or should produce 
a certain amount of immediate disability. A thickened or smooth con- 
dition of the prolapsed portion, with signs of ulcers from attrition, and 
ease of reposition, should readily enable old cases to be excluded. It 
may be assumed that prolapse only occurs as a result of accident in per- 
sons locally predisposed to it. The amount of disability (loss of earning 
power) in the labouring classes is from ten to twenty-five per cent, 
according to the success with which reposition by supports can be main- 
tained. Operation can not be insisted upon if objected to. The 
12 



162 A TEXT-BOOK OF GYNECOLOGY 

aggravation of an existing prolapse by accident may also require com- 
pensation. 

Injuries to the perineum and vagina occur usually through falls in 
a straddling position or from impalement; they generally leave no per- 
manent disability if the immediate effects are recovered from. Lacera- 
tion of the posterior vaginal wall is the most serious lesion. Indirect 
laceration from forcible separation of the thighs during falls has been 
observed. The effects are, of course, most serious when this occurs in 
pregnant women. 

In injuries of the vulva and vaginal orifice, hematoma is the com- 
monest result of injury. It leaves no permanent disability. Tumours 
of the vulva have not yet been recorded as the result of a single injury. 

Uterus. — The nonpregnant uterus is only liable to injury in con- 
nection with some very severe violence, such as fracture of the pelvis; 
but when enlarged from tumours or pregnancy it becomes exposed to 
external trauma; interruption of pregnancy, if such exists, is liable to 
occur, but often does not. 

Cases of pelvic hematocele from trauma have been reported, but in 
those cases where metrorrhagia ensues, the existence of pregnancy is 
extremely probable. The abdominal hemorrhage from ruptured tubal 
pregnancies is practically never due to trauma. Torsion of the pedicle 
of ovarian tumours was found by Thornton to be traumatic in 16 per 
cent of six hundred cases. Laceration and hemorrhage of ovarian 
tumours from contusions of the abdomen have been observed. 

Hydrosalpinx and pyosalpinx never arise from trauma. 



CHAPTEE XVI 

INFECTIONS OF THE EXTERNAL GENITAL ORGANS 

Preliminary remarks — Vulvitis and vaginitis — Bacteriology of the external genital 
organs — Mixed infections — Gonorrhoea — Extirpation of the vulvo-vaginal 
glands — Tuberculosis; vulva; vagina — Erysipelas — Erysipelas and puerperal 
infection — Diphtheria — Aphthae — Aerogenous infection — Bilharzia — Chancroid 
— Hard chancre — Late syphilitic ulcers. 



Infection of the vulva, the vulvo-vaginal gland, and the vagina, de- 
pending upon the action of specific micro-organisms, may or may not 
be limited to — i. e., arrested within — the intrauterine segment of the 
genital tract. There is a proneness on the part of particularly the more 
vigorous pathogenic bacteria to progressively invade contiguous mucous 
areas; it follows, therefore, that infection, once established in the vulva 
or vagina, is liable to extend upward, involving the endometrium, the 
mucous lining of the Fallopian tubes, the peritoneum, and the intra- 
pelvic lymphatics. A proper comprehension of the general subject of 
infection of the female genitalia involves, therefore, a study of the 
various pathogenic bacteria (see Sepsis), a consideration of the micro- 
organisms known to be involved in the infection of these organs, and, 
finally, a study of the infection, not alone of any one organ, but of 
the entire genital apparatus. 

Vulvitis, or inflammation of the vulva, and vaginitis, or inflamma- 
tion of the vagina, were formerly recognised as clinical entities; at 
present, however, vulvitis is discussed under the various forms of skin 
disease of the vulva, or as the result of the action of micro-organisms 
or of traumatism, while vaginitis can hardly longer be said to exist 
except as the result of either infection or injury. Inflammations of the 
external genital organs or of any part of them, except such as occur in 
the recognised forms of skin disease (see Disease of the Skin of the 
Female Genitals), will, therefore, be discussed under the heads of In- 
fections and Injuries. 

Bacteriology of the External Genital Organs. — The bacteriology of 
the vulva and vagina in both health and disease has been very carefully 
investigated by numerous observers. Pioneer work was done by Hauss- 
man, Kehrer, and Karewski, with primitive methods of investigation 
which naturally militated against the accuracy of their results. 
StroganofT, of St. Petersburg, has investigated the bacteriology of the 
vagina of the newborn child, and finds that it is free from micro-organ- 

163 



164 A TEXT-BOOK OF GYNECOLOGY 

isms, which, however, may enter soon after birth. Baths, washings, and 
especially the application of oleaginous substances, such as are fre- 
quently used in the early toilet of newborn children, favour the entrance 
of germs. Winter (CentraTblatt fur Gynakologie, No. 17, 1888) found 
numerous organisms in the vagina and upon the pudendal structures, 
in neither of which were there any manifestations of disease. An in- 
teresting fact was that he found staphylococci, including the Pyogenes 
albus, aureus, and citreus, together with numerous streptococci, all of 
which, in morphology, pigmentation, and behaviour in culture media, 
were identical with similar bacteria found in other loci where they 
possess pathogenic properties; they differed, however, in the particular 
that inoculation experiments indicated that they were innocuous. All 
investigators agree that all pathogenic bacteria lose their virulence the 
nearer they approach the cervix. This circumstance at once raises the 
question whether or not the cervical and vaginal secretions have the 
effect of depriving these bacteria of their virulence. 

In answer to this question may be cited the observations of Doder- 
lein, who has found a bacillus which does not grow upon many of the 
usual media, but may be cultivated on sugar bouillon and sugar agar. 
It produces an acid, apparently lactic, upon which the usual acidity of 
the vaginal secretion depends. Lactic acid, which is elaborated by this 
bacillus in considerable quantity, is presumed to be the agent which 
either destroys the life or neutralizes the virulence of the pathogenic 
organisms. In confirmation of this theory large quantities of pus- 
producing organisms introduced within the vagina disappeared com- 
pletely within a few days. This acid-forming bacillus, which stands 
as a sentinel at the introitus and along the vaginal wall, does not itself 
produce pathologic symptoms, and consequently plays no part in the 
causation of sepsis. Doderlein is of the opinion that this micro-organ- 
ism and the products of its vitality are able to resist the invasion of 
streptococci, which probably never reach the uterus unless either car- 
ried there mechanically or escorted by the more powerful pus-form- 
ers. These latter, notably the gonococcus, overpower the bacillus of 
Doderlein and march practically unopposed to the remotest reaches 
of the genital tract. The fact that the Bacillus aerogenes capsulatus 
manifests its activities upon or near the cervix indicates that it is not 
amenable to the influence of this micro-organism. 

The importance of bacteriological examination of secretions found 
upon the vulva and in the vagina can hardly be overestimated. The 
lesson taught by the investigations of Doderlein and J. Whitridge 
Williams is conclusive upon this point. The investigations of these gen- 
tlemen show that the normal vaginal secretion is of very small quantity, 
of whitish, crumbling material, of the consistence and appearance of 
curdled milk, containing no mucus, and giving an intensely acid reac- 
tion 'to litmus, while microscopically it consists entirely of vaginal 
epithelial cells and a relatively few large bacilli. The pathologic secre- 
tion, on the other hand, is of a yellowish or greenish-yellow colour, 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 165 

creamlike in consistence, often containing gas bubbles (dependent upon 
Bacillus aerogenes capsulatus) and a little mucus, and varies in reac- 
tion from weakly acid or neutral to alkaline, while microscopically it 
consists of epithelial cells, numerous pus corpuscles, and all kinds of 
bacilli. Stroganoff found that micro-organisms seemed to increase in 
abundance in the vaginal secretion preceding and following menstru- 
ation. 

J. Whitridge Williams made a critical study of the secretion in the 
vaginae of ninety-two pregnant women, upon which he based prac- 
tical conclusions (Transactions of the American Gynecological Society, 
1898) as follows: 

1. We agree with Kronig that the vaginal secretion of pregnant 
women does not contain the usual pyogenic cocci, having found the 
Staphylococcus epidermidis albus only twice in ninety-two cases, but 
never the Streptococcus pyogenes or the Staphylococcus aureus or albus. 

2. The discrepancy in the results of the various investigators is due 
to the technique by which the secretion is obtained. 

3. As the vagina does not contain pyogenic cocci, auto-infection 
with them is impossible; and when they are found in the puerperal 
uterus, they have been introduced from without. 

4. The gonococcus is occasionally found in the vaginal secretion, 
and during the puerperium may extend from the cervix into the uterus 
and tubes. 

5. It is possible, but not yet demonstrated, that in very rare in- 
stances the vagina may contain bacteria, which may give rise to 
sapraemia and putrefactive endometritis by auto-infection. 

6. Death from puerperal infection is always due to infection from 
without, and is usually due to neglect of aseptic precautions on the part 
of the physician and nurse. 

7. Puerperal infection is to be avoided by limiting vaginal examina- 
tions as much as possible and cultivating external palpation. When 
vaginal examinations are to be made, the external genitalia should be 
carefully cleansed and disinfected, and the hands rendered as aseptic as 
if for a laparotomy. Vaginal douches are not necessary, and are prob- 
ably harmful. 

Mixed Infections. — A brief consideration of the preceding para- 
graphs relative to the bacteriology of the external genital organs makes 
it evident that they are the frequent seats of coincident infections by 
different micro-organisms. In cases of pelvic suppuration discharging 
into the genital tract, both staphylococci and streptococci are generally 
found, together with other pathogenic micro-organisms. In gonorrhoea 
the diplococcus of Neisser is never the only pyogenic organism pres- 
ent; and in the destructive stages of tuberculosis the tubercle bacillus 
is always found in association with other germs. There are cases, how- 
ever, in which the pathologic changes and clinical phenomena are so 
distinctly attributable to a particular micro-organism that the infection 
is given its name rather than that of its congeners. In this category 



166 A TEXT-BOOK OF GYNECOLOGY 

may be mentioned particularly (a) gonorrhoea, (b) tuberculosis, (c) 
erysipelas, (d) diphtheria, (e) aphthae, and (f) aerogenous infection. 

Gonorrhoea in women was once thought to be a disease restricted 
to the vulva, the vagina, and the urethra; but since the days of Tait 
and Noeggerath it is known that infection of the lower genital canal 
if left to itself may become a progressive invasion of the mucous tract, 
causing infection of the endometrium, the Fallopian tubes, the peri- 
toneum, and the pelvic lymphatics. (See Endometritis and Pyosalpinx.) 
It should be remembered likewise that the lower segment of the urethra 
is also, coincidently with the vagina and vulva, a seat of primary infec- 
tion, and that from this locus it may extend upward, involving the 
bladder and even the kidneys. (See Cystitis.) The cause of this infec- 
tion is the gonococcus of Neisser (see Fig. 17). This organism is the 
morbific agent that is distributed chiefly through the avenue of the 
" social evil," and restrictive measures have been taken in all enlight- 
ened communities to diminish its ravages. The prevalence of this 
micro-organism in the vaginal discharges of prostitutes has been a fre- 
quent subject of investigation. Laser, of Konigsberg, examined a 
number of prostitutes with the result that the gonococcus was found 
in the urethra 111 times in 353 cases; in the vagina 7 times in 180 cases; 
and in the cervical canal 21 times in 67 cases. These figures indicate 
that this micro-organism finds a favourable habitat equally in the ure- 
thra and in the neck of the uterus, and the least favourable abiding 
place in the vagina — a conclusion which supports the observation of 
Doderlein relative to the phagocytic action of the acid-forming ba- 
cillus of the vagina. Out of the 353 patients examined by Laser for 
gonococci in the urethra, four fifths of the 111 cases that revealed this 
micro-organism gave no macroscopical evidence of gonorrhoea. In 241 
patients in whom no gonococci were discovered, there was more or less 
inflammation of the mucosa, often with a suspicious discharge. It 
follows, therefore, that while infection of the genital and urinary tracts 
may depend upon organisms other than the gonococcus, the latter, in 
a degenerated form located deep in the mucous folds and follicles, but 
especially in the crypts of the vulvo-vaginal gland, may be a persistent 
cause of the disease, even when it can not be detected in the dis- 
charges. It is evident from these facts that gonorrhoea in women 
should be classified as acute and chronic. 

Afanassiew (Gazette de gynecologies No. 167, p. 173) reports the 
results of bacteriological investigation of the lochia of twenty-four par- 
turient women. Out of sixty-eight examinations, he obtained cultures 
in nearly all the cases. The bacteria diminished in the vagina from 
without inward, and were fewest at the uterine cavity — an observation 
confirmatory of the conclusions of Doderlein. They were living and 
culturable, notwithstanding daily washing of the canal with carbolized 
water of 2-per-cent strength. 

The gonococcus of Neisser is often demonstrable in secretions from 
the vagina and vulva. These organisms are frequently found in appar- 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 



167 



ently nonpurulent secretions long after the period of acute infection 
has passed; their virulence, however, under such circumstances is gen- 
erally greatly reduced, often to the degree of having lost their patho- 
genic properties. (See Gonorrhoea in Women.) Freymuth and Pe- 
truschky (Deutsche medicinische Wochenschrift) have found the diph- 
theria bacillus in noma of the vulva. The same organism has been dem- 
onstrated in exfoliative vaginitis not associated with gangrenous ulcera- 
tion, while Eisner and others have reported puerperal diphtheria in- 
volving the vagina and endometrium. The Oidium albicans has been 
demonstrated in aphthous inflammations of the vulva and vagina in 
both children and adults. 

The symptoms of acute gonorrhoea in women consist of a burning 
pain on urination located at first in the meatus urinarius, and next upon 
the inner and erythematous surfaces of the vulvar folds; and in a copious 
creamy discharge, bathing the vulva and matting the pudendal hair. 
On inspection the vulva reveals areas of erythema, which, after a few 
days, owing to the destruction of the epithelium, may become distinct 
erosions; the urethra is tender to the touch, swollen, and its mucous 
membrane is more or less everted at the meatus urinarius. The diagno- 
sis may be made presumptively upon the foregoing symptoms coupled 
with the fact of probable exj)osure to infection; but it can be made 
positively only upon the demonstrated presence in the discharge of 
the gonococcus of Neisser. The practitioner should be very cautious 
in giving a final diagnosis of suspected cases of gonorrhoea, on account 
of the possible social and medico-legal contingencies that may arise. 
The symptoms of chronic gonorrhoea in women are more obscure. There 
is generally a history of a preceding acute attack, the exact character 
of which may not be known to the patient herself, but which can 
be determined, at least approximately, by Avell-directed interrogatories. 
Following the supposed cure of the acute attack there has been a per- 
sistent catarrhal discharge, varying in colour from a whitish to a 
slightly yellowish tint, and varying in quantity from slight to consider- 
able. If these conditions exist associated with a present or a past sup- 
puration of the vulvo-vaginal glands, and if there is a petechial pur- 
plish red area about the orifice of the vulvo-vaginal ducts, the presump- 
tion of chronic gonorrhoea is strengthened. If the mischief in the 
vulvo-vaginal glands has gone to the extent of suppuration, resulting 
in fistulae or cystic degeneration, the diagnosis may be considered as 
confirmed. The involvement of the urethra, dark-red spots upon a yel- 
lowish-white streaked base upon the vulva, and venereal warts, are com- 
plications of conclusive diagnostic significance. Oskar Bodenstein 
(Deutsche medicinische Wochenschrift) quotes Sanger to the effect that 
the local application of a 50-per-cent solution of zinc chloride will 
cause the granules in the vaginal mucous membrane to spring into 
relief in chronic gonorrhoea — a convenient diagnostic expedient that is 
certainly worthy of investigation. 

The pathology of gonorrhoea in women has been understood but re- 






168 A TEXT-BOOK OF GYNECOLOGY 

cently. Its comprehension involves a study, not so much of the changes 
that occur in the vulva, vagina, and urethra, as of those occurring in 
the bladder and kidneys, and in the uterus and its adnexa, to the 
chapters upon which subjects the reader is referred. The pathology 
of gonorrheal infection of the vulva and vagina is essentially the 
pathology of an infective inflammation. The micro-organisms, find- 
ing a lodgment upon the mucous surfaces of the urethra, in the 
muco-cutaneous folds of the vulva, or those about the introitus 
vaginae, readily propagate in the secretions which act as culture media. 
The direct irritating influence, both of the organisms themselves and 
of the products of their vitality, results in the establishment of the 
ordinary phenomena of inflammation — congestion, stasis, exudation, 
etc. The direct action of these organisms and their products is, to a 
certain extent, destructive of the epithelium, which, however, would 
probably withstand the assaults of the invaders if it were not for the 
circulatory and nutrient changes in progress in the underlying struc- 
ture. Through these combined influences the protective epithelium is 
broken down and there is more or less direct invasion of the under- 
lying cuticular structure; but even here the intrusive cocci are con- 
fronted by other defenders of the system in the form of leucocytes. 
Cocci develop rapidly, however, overcome their cellular antagonists, 
and find their way into the fimbriated intercellular substance and into 
pre-existing cells of the tissue and in the vessel walls. While these 
changes are in progress, however, the mucous follicles are invaded, and 
with the first temporary recession of the local circulatory pressure these 
follicles are stimulated to extreme activity, manifested in that hyper- 
secretion which is generally designated as catarrhal. In the presence of 
a virulent infection these follicles and glands, including even the vulvo- 
vaginal glands, may suffer the loss of their epithelium and themselves 
become the avenues for tissue infection. Local abscesses as the result 
of gonococcus infection but rarely occur, except in the vulvo-vaginal 
gland, -the efferent duct of which may become occluded, converting the 
gland into a suppurating retention cyst. Tissue invasions, such as have 
been described, more frequently result in permitting the passage of the 
pyogenic organisms — for by this time the infection has generally become 
more or less mixed — into the lymph channels, whence they are carried 
to the lymphatic glands, particularly to those in the groin, where, not 
infrequently, the infection results in abscesses. Coincidently with these 
changes there occurs more or less systemic intoxication, expressed, it 
may be, by an initial rigour; this is followed by an elevation of tem- 
perature, which persists with slight but irregular vacillation until the 
focus of suppuration has been opened and drained. 

Treatment. — When gonorrhoea is limited to the vulva, the urethra, 
and the ostium vaginae, it should be treated by rest, and antiseptic 
lotions of either boric acid or bichloride of mercury emollient appli- 
cations. The vagina will seldom be invaded unless the infection is 
carried upward by mechanical means. This, however, is what unfor- 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 169 

tunately happens in the majority of cases long before the physician is 
consulted. The patient of her own accord is prone to use the douche; 
or, may be before she has become aware of her condition, she has 
indulged in repeated acts of coition. The physician is, therefore, called 
upon at the very outset to treat a thoroughly infected vagina. L T nder 
these circumstances there is no disease with which women are afflicted 
that calls for more prompt, more vigorous, and more efficient treatment 
than that of acute gonorrhoea. Its probable extension to the upper 
reaches of the genital tract, with the inevitable complications thereby 
engendered, should stand before the practitioner as a spectre warning 
him to the fullest discharge of his duty. The treatment of acute gonor- 
rhoea is essentially bactericidal. It should begin with a thorough cleans- 
ing of the parts; this can be accomplished thoroughly only by first 
shaving the pudendum; a douche of tepid water, either clear or holding 
in solution some borax or sodium bicarbonate, should be used to cleanse 
the vulva and the vagina; after this has been thoroughly done another 
douche of l-to-2,000 bichloride solution should be employed for a period 
of from ten to fifteen minutes. This douche should be given, as should 
the preceding, with the patient lying upon her back, her buttocks drawn 
to the edge of the bed, in which position the nurse can practise most 
thorough cleansing of the vagina by repeatedly holding her hand over 
the vulva, thus forcing the retention of the irrigating fluid in the vagina; 
the hydrostatic pressure thus exercised will occasion that degree of dis- 
tention of the vagina which will cause an obliteration of the folds and 
the exposure of its entire surface to the action of the medicament. 
Care should also be taken to bring the antiseptic solution in contact 
with every part of the infected area of the vulva. An older and pos- 
sibly more efficacious, but certainly more severe, treatment consists in 
cleansing the parts as above described, and in then introducing a specu- 
lum, widely distending the mucous membrane of the vagina, which, 
with the entire vulvar surface, is cauterized with a solution of nitrate 
of silver, twenty grains to the ounce; this cauterization, to be effective, 
should be thorough and should include every part of the mucous mem- 
brane. After the silver nitrate has been applied, a loose pledget of cot- 
ton, saturated with glycerine, should be carefully inserted, not so as to 
pack the vagina, but to lie lengthwise in the canal, preventing the ap- 
proximation of the cauterized surfaces. Other remedies, such as the 
zinc sulphate, plumbic acetate, tannin, carbolic acid, lysol, and creolin, 
have been suggested and may be employed; they, however, possess vary- 
ing germicidal properties, none of them being so valuable as either the 
mercuric bichloride or the silver nitrate. AVhen the nitrate of silver is 
used, it should not be reapplied under three or four days. It should 
be remembered that antiseptic treatment, to be effective, should be con- 
tinued until the symptoms of infection have subsided. It is not enough 
to kill an existing generation of bacteria, even though it were possible 
to do so in a given case, for it should be remembered that many of these 
micro-organisms propagate by spores, which resist more effectively than 



170 A TEXT-BOOK OF GYNECOLOGY 

do the parent organisms themselves the action of germicidal agents. 
Doderlein has emphasized the importance of repeated disinfections of 
the genital tract, for the purpose of securing sterilization, and his 
teachings should pass into an axiom of practice. The treatment of 
chronic gonorrhoea in women involves a much more comprehensive 
regimen. It must be based upon a comprehension of the pathologic 
changes that have occurred in the case at hand. This may involve 
the application of surgical expedients to the bladder, the kidneys, the 
uterus or its adnexa, or to the pelvic lymphatics. So far as the treat- 
ment of chronic gonorrhoea of the lower genital tract is concerned, it 
will resolve itself into a persistence in antiseptic measures, or the ex- 
tirpation of the vulvo-vaginal gland, which is generally found to be the 
persistent fons et origo of the disease. The antiseptic treatment should 
consist in the continued practice of irrigation with strong solutions of 
bichloride of mercury or carbolic acid, always taken in the recumbent 
posture, the douche bag being elevated from four to five feet above the 
patient, the nurse practising forced retention of the fluid in the pa- 
tient's vagina. It should be kept in mind that chronic gonorrhoea of 
the vagina is a deep-seated process, for the successful treatment of 
which vaginal distention is a necessity. Forcible tamponade of the 
vagina, particularly in the lateral fornices and in the upper segment 
of the canal, should be practised by saturating a long slender cotton 
tampon with sterilized glycerine. The exosmotic influence of this 
agent has a tendency to wash the micro-organisms out of their hiding 
places and to bring them in contact with the stronger sterilizing agents. 
In these cases it is of special value to distend the vagina to the extreme 
by means of a multivalvular speculum, and to cauterize the thus tense 
and distended mucous surface with a strong solution of nitrate of silver, 
followed with glycerine tamponade. The escharotic influence of the 
silver salt is not sufficient to produce serious destruction of the mucous 
membrane, unless frequently applied — i. e., oftener than every three or 
four days. 

Extirpation of the vulvo-vaginal glands should be practised when- 
ever they have become the seat of gonorrhoeal infection, as evidenced 
by either repeated suppurations or cystic degeneration. This gland is 
also the occasional seat of malignant disease, the existence of which is an 
indication for its prompt removal. This is an operation of more magni- 
tude than the anatomic structures involved would seem to imply. With 
the patient in the dorsal position, the vulva having been completely 
sterilized, the labia of the affected side are retracted by the hands of the 
assistant or nurse, and an incision is made over the gland just at the 
base of the labium minus. If the gland is distended, dissection should 
be made with considerable care until the cyst, as the gland may be now 
designated, is encountered; an effort should be made to carefully enu- 
cleate this body, which will be found to be held in position by a sort 
of ligamentous structure, conveying its nerves and nutrient vessels. 
These are of sufficient magnitude to occasion severe hemorrhage, and 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 171 

if they are permitted to elude the grasp of the operator, they retract 
along the vaginal wall to such an extent that they are re-secured with 
extreme difficulty. Care should be taken, therefore, to get them with- 
in the grasp of a hemostatic forceps before excising the gland, and 
to ligate the pedicle before taking off the forceps; the wound should 
then be closed aseptically and dressed with protective pads. If closed 
by the buried suture the liability of subsequent infection from external 
causes is minimized. 

Tuberculosis of the vulva is a specific inflammatory disease of the 
external genitalia, caused by the presence of the tubercle bacillus and 
characterized by both the anatomic lesions and clinical course of lupus. 
It may exist as a primary disease confined to the vulvar region or a 
secondary manifestation of tuberculous lesions in the lung, intestine, 
or internal genital organs. 

A clear definition of tuberculosis of the vulva is extremely difficult 
to give in the presence of the confusing classifications of different 
authors, and must in reality include a very extended description and 
differentiation of the conditions — ulcus rodens vulva?, elephantiasis, 
lupus vulva?, Testhiomene, and destructive ulcer. Veit, Schroder, 
Pozzi, and many others have described ulcus rodens vulva? as a distinct 
lesion, but they also state that the tubercle bacillus has often been found 
in such ulcers. It will certainly simplify the subject greatly and bring 
it more within the limits of this short article to look upon this division 
as sub judice, and to describe only a tuberculosis of the vulva. 

Etiology. — Until recent times tuberculosis of the vulva has been 
considered so rare that it has been given no place, or only passing- 
mention, in the accepted text-books of gynecology; but the reported 
cases of Demme, Schenck, Kuttner, Karajan, Paoli, Kelly, Eieck, and 
others, would indicate that the disease occurs with greater frequency 
than is generally believed, and that this condition must always enter 
into the diagnosis of vulvar ulceration. Barbier (Gazette medicate) 
believes that a woman can be infected by a tuberculous man during 
coitus. Bacilli have been demonstrated in the semen as well as in the 
discharge attending tuberculous epididymitis. The uterus may be in- 
fected by extension from a tuberculous growth on the vulva, without 
any intermediate trace of infection in the vagina. He even admits the 
possibility that tuberculous infection may be transmitted by the finger 
of the attendant, by unclean instruments, or even through the medium 
of the air. It is manifest, however, that infection transmitted in this 
way must be taken up through some rent in the continuity of the epi- 
thelium. 

The disease occurs alike in children and adults and without refer- 
ence to the general nutrition. The infection would seem to be by the 
direct inoculation of a skin abrasion by means of the nails, by infected 
dust, by tuberculous stools, or by coitus. The case of Schenck occurred 
in a child who had two tuberculous playmates, and who had no other 
tuberculous manifestations. Prostitutes are most frequently attacked, 



172 



A TEXT-BOOK OF GYNECOLOGY 



a fact that has its explanation in their great liability to direct infection, 
in continued irritation, and in lack of cleanliness. Masturbation serves 
as a predisposing cause, and syphilis also by lowering the resistance 
of the tissues. Koch has considered extirpation of the inguinal glands 
to be a predisposing cause. 

Morbid Anatomy. — The starting point of the tuberculous process is 
usually in the region of the urethral orifice or the clitoris, or in the 
posterior commissure. The lesion begins as a single or as multiple 
hard masses, of a dark-red or livid colour, which develop in an indu- 
rated skin and increase in size very slowly. This mass may exist for a 
long time as a firm nodule, or in the clitoris as a hypertrophy, or it 
may soften in the centre and break down to form a small, raised, un- 
healthy ulcer with ragged edges, which exudes a serous fluid. It is in 
this stage of ulceration that the patient usually presents herself for 
treatment. When the lesions are multiple, a number of such discrete 
ulcers will form on the vulva and gradually run together to form an 
extensive area of tuberculous granulations involving the entire vesti- 
bule, clitoris, labia, and lower part of the vagina. The granulations of 

such an ulcer are un- 
healthy, friable, do 
not bleed easily, and 
show no tendency to 
caseation. The sur- 
face is covered by 
a sero-purulent exu- 
date. There is a rich 
vascularization of the 
part and the tissues 
around and beneath 
the ulcer are strongly 
infiltrated, but not 
markedly indurated. 
These ulcers are apt 
to be serpiginous in 
character, healing be- 
hind as the advance is 
made. A very char- 
acteristic feature of 
the disease is a rough, 
tense, hard elephanti- 
asic thickening of the 
labia or clitoris, or both, which causes them to swell to two or three times 
their normal size. In fact, in the cases of Karajan and De Sinerty the 
operation was done for elephantiasis of the clitoris, and the tuberculous 
nature of the disease was revealed only by histological and bacterio- 
logical examination. A microscopic examination of these ulcers shows 
the base to be made up of a thin layer of tuberculous granulations and 




Fig. 68. — " A low power shows the caseous areas (5, c) in the 
tuberculous tissue and an occasional fistulous tract (a)." — 
Whitacre (page 173). 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 



173 




Fig. 69.— "A high power picture demonstrates small round 
cells and giant cells around the irregular caseous areas." — 
Whitacre. 



the raised edges of 
solid tuberculous tis- 
sue containing more 
or less typical mili- 
ary tubercles. A low 
power (Fig. 68) shows 
the caseous areas in 
the tuberculous tis- 
sue and an occasional 
fistulous tract. A 
high power (Fig. 69) 
demonstrates small 
round cells and giant 
cells around the ir- 
regular caseous areas. 
Tubercle bacilli may 
be demonstrated (Fig. 
70) among the small 
round cells in the 
secretions or in the 
newly formed tissue. 
It must be remem- 
bered, however, that in the serpiginous course of such a tuberculous 
lesion the older parts of the ulcer may show the entire absence of tuber- 
cle bacilli, as is shown by the interesting case of Eieck (Fig. 71). The 
involvement of the urethra is progressive, its inner surface loses 

its real mucous-mem- 
brane character, is 
more or less exposed, 
and may be con- 
verted into scar tis- 
sue. The meatus ap- 
pears to be torn lat- 
erally, as Emmet has 
pictured it for the 
cervix. The process 
continues until the 
urethra is almost en- 
tirely destroyed and 
is represented by a 
funnel-shaped ulcer. 
The course of the 
ulcerative process is 
very slow, however, 
and the inguinal 
glands remain free 
for a remarkably 




70. 



-" Tubercle bacilli may be demonstrated among 
the small round cells." — Whitacre. 



174 



A TEXT-BOOK OF GYNECOLOGY 




long time. Cicatrization is sometimes associated with the ulceration, as 
an evidence of a tendency to spontaneous healing, and may lead to great 
deformity. 

Fistulse often form a marked feature of the disease, and especially 
in ulcus rodens vulvae. A tendency to a deep penetration of the tissues 
may be present from the start. They first form underneath the mucous 
membrane, but very soon penetrate deeply, and may communicate with 
the rectum high up at the upper end of the perineal triangle. Three 

or four sinus open- 
ings on the vulva may 
coalesce below the 
surface and open into 
the rectum as a sin- 
gle channel. Ulcera- 
tion in the perineal 
body may be so ex- 
tensive as to form a 
cloaca. 

Symptoms. — The 
first symptom of pri- 
mary tuberculosis of 
the vulva is often a 
stinging pain on uri- 
nation, caused by the 
urine coming in con- 
tact with a minute 
ulcer at the orifice 
of the urethra. At 
other times an ulcer giving no symptoms is discovered by the patient, or 
the nympha of one side, or the clitoris, is found to be increasing in size. 
A physical examination will reveal the presence of one or more ulcers 
possessing the above-named characteristics. The course of such an 
ulcerative process is extremely slow, and may continue for many years 
as a local phenomenon without affecting the general health of the 
patient. The dribbling of urine and rectal irritation will, of course, be 
present in the advanced cases as most distressing symptoms. Death will 
eventually result from involvement of the internal organs. 

A secondary tuberculosis of the vulva takes a much more rapid and 
malignant course; furthermore, the vulvar disease often possesses little 
significance in comparison with the primary lesion in the lung or other 
organs. 

Diagnosis. — The diagnosis of this condition possesses a consider- 
able degree of importance, first, because of the necessity of radical 
treatment, and, secondly, because of the difficulty experienced in ar- 
riving at a correct diagnosis. Askanazy has explained certain of these 
difficulties by the demonstration that we may meet with tumours not 
differing in their microscopical anatomy from typical tuberculosis, but 



Fig. 71. — The case of Kieck : A, C, sinus openings ; B, F, scar- 
tissue ; D, a small tumour containing typical tubercle tissue ; 
E, ulcerated surface ; G, urethra ; H, introitus vagina ; J, ele- 
phantiasic thickening of left nympha. — Whitacre (p. 173). 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 175 

characterized clinically by an absence of all tendency to caseation, 
abnormally large size of tumour formation, firm consistence, and, lastly, 
by a tendency to fibrous metamorphosis which may eventually lead to 
a complete obliteration of all specific tuberculous attributes. 

The association of ulceration with elephantiasic thickening of the 
labia, the slow development, the chronicity of the ulceration, and, most 
important, the demonstration of tubercle bacilli in the secretions, will 
serve to distinguish it from carcinoma. Simple elephantiasis is not 
associated with ulceration. Chancroid will usually be diagnosed by 
its history and clinical characteristics, by the absence of elephanti- 
asis, by its multiple character, by its short duration, and by the absence 
of extensive and deep destruction of tissue. 

Treatment. — The treatment of tuberculous lesions of the vulva is 
surgical, and a radical removal of all diseased tissue should be resorted 
to whenever this is possible. This will often require an extensive plas- 
tic operation, and it should be remembered that a considerable removal 
of urethral tissue can be made without impairing the function of the 
bladder (Kelly, Schroder, Paoli). When this is not possible, thorough 
curetting with a sharp spoon, followed by cauterization with strong 
acids, may be tried and repeated as often as the disease recurs. Deep 
cauterization by the electro-puncture serves as an excellent method of 
thoroughly removing the diseased tissue and securing good cicatriza- 
tion. The ulcers unfortunately heal very well oftentimes under such 
simple applications as iodine or acids, but this cure is not permanent, 
and the ulcers recur. Under any plan of treatment these cases should 
be carefully followed up and the slightest recurrence treated as radi- 
cally as the original focus of infection. Enlarged glands in the groin 
should be removed at the time of the primary operation or in the in- 
stance of their later enlargement. Either as an auxiliary to the ordi- 
nary methods of treating lupus, or as an independent method, Unna ad- 
vises (MonatsJiefte far praktische Dermatologie) the following lotion: 
I>. Corrosive sublimate, 1 part; carbolic acid or creosote, 4 parts; alco- 
hol, 20 parts. The nodules are attacked in series of tens, beginning 
with those at the edge of the patch. They are first punctured with an 
aene lance, and a minute shred of absorbent cotton moistened with the 
lotion is inserted by means of a sharpened stick, the cotton rotated and 
allowed to remain for ten or fifteen minutes. In a few days the punc- 
tures and lupus deposits so treated have almost disappeared, and other 
nodules may be then similarly attacked. This method, Unna believes, 
has many advantages over the somewhat similar plan of treatment 
by means of the nitrate-of-silver stick. 

Tuberculosis of the vagina is usually associated with tuberculosis 
of the higher portions of the genital tract, but a number of cases have 
been reported in which no other focus could be discovered in the genital 
tract, and a single case is reported by Friedlander in which a vaginal 
ulcer represented the only tuberculous lesion to be found in the entire 
body. The vagina certainly may be infected from a tuberculosis of 



176 A TEXT-BOOK OF GYNECOLOGY 

the peritoneum or tube without involvement of the intervening organs 
(Oppenheim), and it was Reynaud who first explained the usual seat of 
the first vaginal lesion in the posterior fornix, by the observation that 
it was here that virus-laden secretions from above first came in con- 
tact with the vagina. The infection may also be introduced from with- 
out by coitus with men suffering from a tuberculous disease of the sexual 
organs, by the hands or instruments of the physician or midwife, from 
the urine, from filthy bed linen or wearing apparel, from the air, from 
the blood (Davidsohn), and by infection in continuity of tissue from 
neighbouring organs, as in vesical or rectal fistula?. 

The infrequency of the disease in both the vagina and vulva, as 
compared with that of the higher organs, is probably to be explained 
by the natural resistance of squamous epithelium to bacterial invasion, 
and it is only after injury, abrasion, or the action of irritating secretions, 
that the tubercle bacillus can gain entrance to the tissues. 

The disease occurs with greatest frequency during the period of 
sexual activity (twenty to forty), yet seven and seventy-nine represent 
the two extremes of age in the collected cases. 

Morbid Anatomy. — Two cases in particular are reported where the 
entire lesion consisted in an eruption of perfectly typical, fresh miliary 
tubercles over the entire vaginal wall. These tubercles were of millet- 
seed size, and were made up microscopically of giant, epithelioid, and 
small round cells, which were supported by a delicate reticulum and 
showed areas of caseation. Tubercle bacilli were present. Favoured by 
moisture and warmth, these miliary tubercles soon break down to form 
minute ulcers, or by their confluence will form larger sharply defined 
but irregular ulcers. Such ulcers are characterized by perpendicular 
edges, a depressed grayish or yellowish-gray base, studded by tubercles 
and covered by caseous material, a size varying with the extent of the 
confluence, and a decided tendency to the serpiginous type. Such an 
ulcer is usually surrounded by an area of hyperemia, which is more or 
less filled with small, yellow, opaque, grainlike miliary tubercles. The 
usual seat of ulceration, as has already been stated, is in the posterior 
fornix. When the infection is from without, however, the lower por- 
tion of the vagina will be first involved. Tuberculous fistula? are found 
in the later stages of the disease and are formed, as a rule, by an ulcera- 
tion into the connective tissue, thence into urethra, rectum, bladder, or 
the skin surface of the perineum. On the other hand, fistula? may be 
the result of perforating rectal or vesical ulcers, and cases have been 
reported in which the fistula has its origin in a broken-down tubercu- 
lous Fallopian tube. These fistula? are peculiar only in the fact that 
they are lined by the tuberculous membrane. 

Symptoms. — The symptoms of tuberculous vaginitis are, as a rule, 
masked by those of the tuberculous disease existing in other parts of the 
body. A leucorrhcea associated with painful coitus or pain in using the 
douche tube will usually be the first symptom that brings the patient 
to the physician for examination, or the symptoms of a vesico-recto- 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 177 

vaginal or urethrovaginal fistula may be the first that are referred to 
the vagina. A physical examination will reveal one or many sensitive 
ulcers possessing the above-named characteristics. 

The diagnosis of the miliary form from granular vaginitis should 
not present great difficulties when we remember the frequency of 
the latter as compared to the condition under discussion, also its 
usual association with pregnancy and gonorrhoea. Furthermore, the 
character of the ulceration, and the fact that a tuberculous lesion of the 
vagina is almost invariably associated with a similar lesion elsewhere 
in the body, will prevent confusion. A chancre can be easily distin- 
guished from a tuberculous ulcer by its history and clinical course; the 
papular or ulcerative syphilides by the history, the total lack of pain, 
and mainly by their disappearance under antisyphiltic treatment. The 
reports of many of the recorded cases state that the patient was first 
subjected to antisyphilitic treatment, leading to the impression that 
this confusion often arises. Finally, the secretion of every persistent 
ulceration of the vagina or vulva should be subjected to bacterial ex- 
amination in smear or culture preparations, or inoculated into the peri- 
toneal cavity of guinea-pigs. The number of bacilli is often too few 
for easy demonstration by ordinary staining methods, yet it will cause 
a tuberculous peritonitis in the guinea-pig in from three to four weeks 
when present in very small numbers. A microscopic examination of a 
snipping from the edge of the ulcer may be necessary to distinguish 
the condition from carcinoma. 

The treatment of tuberculous vaginitis should be as radical as possible 
when the lesion can be demonstrated to be a primary one, either in the 
genital tract or in the body; but it must be remembered that the condi- 
tion is usually secondary to a much more serious tuberculous involve- 
ment of the Fallopian tubes, the uterus, the intestine, or the lungs. 
In these cases palliative measures alone are indicated. When complete 
excision of the ulcers is possible this should be done, but we must very 
often limit ourselves to a thorough curetting and cauterizing of the 
ulcer, and a prompt treatment of every point of recurrence. Palliative 
measures will consist in local applications to the ulcers, the repair or 
cleaning of fistulae, the maintenance of an antiseptic condition by the 
use of astringent and antiseptic douches, the use of general tonics — in 
fact, the use of those measures which are applicable to tuberculosis in 
other parts of the body. 

Erysipelas of the external genital organs, and particularly infection 
of the genital tract by the Streptococcus erysipelatos {Streptococcus 
pyogenes), are occurrences of tragic importance. When the infection is 
strictly local, the streptococcus finding ingress through some abrasion 
in the epithelium, the resulting phenomena are those of erysipelas in- 
volving the pudendal structures. The virus, once admitted to the field 
of propagation, spreads rapidly through the lymph capillaries of the sur- 
rounding skin. The symptoms that ensue are sudden attack of febrile 
disturbance ushered in by a rigor; the tongue becomes coated, there is 
13 



178 A TEXT-BOOK OF GYNECOLOGY 

a sense of depression over the stomach, and malaise, with possible noc- 
turnal delirium; swelling of the infected point occurs, associated sooner 
or later with generally coincident tenderness in the inguinal lym- 
phatics. The swelling in the vulva progresses rapidly and is associated 
with pain, throbbing, and a sense of heat and dryness; itching is gener- 
ally an early and persistent symptom, while diffuse infiltration occasion- 
ing oedema of the cellular tissue of the vulva rapidly supervenes. 
Minute vesicles may be discovered, usually arranged in groups, and 
manifesting themselves in the surface of the skin. The smaller of 
these vesicles commonly rupture, the resulting discharge of clear or 
slightly yellowish serum, occasionally tinged with blood, desiccates, and 
forms crusts. The characteristic feature of this inflammation is to 
spread rapidly from the point of primary infection. This extension 
may occur until it involves not only the pudendal structure, lower part 
of the abdomen, and the inner aspect of the thighs, but it may extend 
upward into the vagina; it may, indeed, assume the type of " wander- 
ing " erysipelas, and invade practically the entire surface of the body 
before it is arrested. The subcutaneous infection may result in the 
formation of foci of suppuration, manifesting themselves on the surface 
of the skin in the form of large purulent blebs, or, if more deeply seated, 
as fluctuating masses. The treatment should be both local and constitu- 
tional. Of the local remedies, carbolic acid in solution with liquid vase- 
line painted on the surface with a soft brush has the merit of being 
both convenient and effective. While the disease is yet limited to the 
vulva, a 5-per-cent solution may be employed; but when the infection 
involves a greater area a solution of not more than 1 per cent should 
be used. Creolin and phenol are really but milder forms of the same 
treatment. Concentrated solutions of salicylic acid and of sulpho- 
carbolate of soda, respectively, have been employed subcutaneously 
around the circumference of the infected area. Comfort is derived 
from any soft soothing application which will protect the inflamed 
surface from the air. Silk saturated with carbolized liquid vaseline or 
with carbolized vegetable oils is a source of comfort, care being taken 
to maintain, as nearly as possible, an equable temperature in the parts. 
When suppurations occur they should be freely incised, the cavities 
being treated antiseptically. 

Erysipelas as a source of puerperal infection was first recognised by 
Dr. Oliver Wendell Holmes, his conclusion being based upon the occur- 
rence of a number of deaths from puerperal fever in the practice of a 
physician whose finger was known to have been infected while making 
an autopsy of an erysipelatous subject. The conclusion thus arrived 
at by the Autocrat of the Breakfast Table has since been confirmed 
by the clinical experience of the world. The organism of erysipelas, 
isolated by Fehleisen, was demonstrated by Clivio and Monti in cases 
of puerperal peritonitis. (See Streptococcus Erysipelatos, ante.) The 
clinical phenomena produced by this special micro-organism while the 
infection is limited to the vulva and vagina are not known, for the 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 179 

reason that, in puerperal cases, the occurrence of this infection is not 
detected nntil it has invaded the endometrium, at which time it is 
readily demonstrable in the lochia. As the ensuing essential clinical 
phenomena are manifested in connection with endometritis, and as the 
treatment of this infection depends upon the successful treatment of 
an infectious endometritis, the reader is referred to the chapter on 
that subject. 

Diphtheria of the External Genital Organs. — The inner surfaces of 
the vulva and vagina are sometimes the seat of active diphtheritic infec- 
tion, which may be either (a) primary or (b) secondary. The latter 
form, in which the genital manifestation of the disease occurs sec- 
ondarily to its appearance either in the upper air-passages or other loci, 
is the more frequent. Leick, of Greifswald, reported a case of primary 
diphtheria involving the inner aspects of the labia and extending into 
the vagina, the characteristic exudate yielding the Klebs-Loemer ba- 
cillus. Eisner has recorded a case of primary infection of the vagina, 
by the same bacillus, in a puerperal ease. Infection of the vulva by 
the diphtheria bacillus, whether primary or secondary, in very young 
subjects may cause noma, or circumscribed gangrene of some part of 
the vulvar structure. 

The symptoms of diphtheria of the vulva and vagina consist of an 
initial chill followed by fever of 105° F. or more, rapid but feeble pulse, 
prostration — less marked, however, than when the disease attacks the 
respiratory passages — local tenderness, referable to the vulva or vagina 
or both, which, upon inspection, reveals the characteristic pearly exu- 
date. The absolute diagnosis depends upon the demonstration of the 
Klebs-Loeffler bacillus. 

The treatment is both constitutional and topical. Constitutional 
treatment consists in the employment of the antitoxine; the complete 
disappearance of the membrane has been noticed in sixty hours fol- 
lowing the use of two thousand units of antitoxine. When the local 
infection is so virulent as to cause noma or circumscribed gangrene of 
the external structures, hot antiseptic applications should be made and 
the sphacelus, as soon as well defined, should be removed, every prin- 
ciple of antisepsis being observed in the subsequent treatment. 

Aphthae, or thrush, is a species of infection that frequently involves 
the vulva and vagina, particularly in nursing women. It depends for 
its occurrence on the Oidium albicans, a vegetative organism that fre- 
quently infests the mouths of children. Its appearance in the external 
genital organs does not differ materially from that in the infant's 
mouth. Infection occurs in discrete areas elevated with an inflamma- 
tory base and covered by a milky white exudate. It causes some local 
pain with but trifling constitutional disturbance. The treatment con- 
sists in thoroughly cleansing the part with sterilized water, applying, 
subsequently, a strong mercuric bichloride solution, followed by a tam- 
pon saturated with boroglyceride. The treatment should be repeated 
daily for two or three days. 



180 A TEXT-BOOK OF GYNECOLOGY 

Aerogenous Infection of the Genital Organs. — Suppuration attended 
with gas formation has long been recognised. Rosenbach studied these 
phlegmons as they occur in different parts of the body and described 
what he designated as the " emphysema-bacillus," which he isolated on 
cover-slip preparations. Arloing described a gaseous panophthalmitis 
of traumatic origin. Levy, in 1891, isolated a short, fine, nonmobile ba- 
cillus from gas-bearing pus of a pelvic abscess. Other investigations 
have been made by William Koch, Kitasato, Wicklein, Chiari, and 
Frankel, the last named of whom isolated, from gas-producing pus, a 
short, plump, nonmobile bacillus with rounded ends to which he gave 
the name Bacillus phlegmonis emphysematosus. While to Frankel credit 
must be given for originality, priority of discovery must be given to 
Welch and Nuttall (Medical News, September 24, 1892), who isolated 
the organism which now stands in the literature by the name they 
gave it — viz., the Bacillus aerogenes capsulatus. 

Infection of the vagina, manifestly due to a gas former, was first 
described by Braun (Zeitschrift fur Gesammte der Aerzt im Wien, 
1861). The infection manifests itself by the formation of cysts, or, 
more properly, air vesicles on the surface of the vagina and on the 
external mucous membrane of the cervix. These vesicles are close set, 
glistening, and vary in size from a millet to a hemp seed. When punc- 
tured, as a rule, nothing but air escapes from them; in a few cases, how- 
ever, the cysts have yielded a slight amount of pale yellow nbnviscid 
fluid. Of twenty-one cases collected by Herman, seventeen were in 
pregnant women. Zweifel (Archiv fur Gynakologie) analyzed the gas 
from these vesicles and found it to be trimethylamine. He made his 
tests by cleansing the vagina and then filling the speculum with test so- 
lutions under cover of which the vesicles were punctured. In this way 
he was able to eliminate ammonia, carbonic acid, coal gas, and hydric 
sulphide. The smell suggested the latter in small quantities. The 
odour was peculiarly like that of the plant Chenopodium vulvaria, which 
is due to trimethylamine. The treatment of this form of infection con- 
sists in puncturing the vesicles as they appear and washing their cav- 
ities and the vagina with antiseptic solutions. The vesicles show no 
disposition to return after being once punctured. 

Bilharzia of the vagina depends for its existence upon infection of 
that canal by the Distoma haematobium of Bilharz, an organism be- 
longing to the genus of distomatous parasites (Cobbold), and is a cylin- 
drical worm of the order Trematoda. The male is about half an inch 
long and the female is a little longer and more slender. It abounds in 
Africa, and when infecting the system it is generally found in the por- 
tal vessels, and in the veins of the mesentery and of the urinary tract, 
causing profound constitutional disturbances, hematuria, anaemia, and 
diarrhoea, being among the more prominent symptoms. This parasite 
generally affects men who work in water, and, in the majority of cases, 
produces serious local disturbances in the mucous membrane of the 
bladder, where it causes single or grouped excrescences, not unlike con- 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 181 

dylomata, with or without pedicles, and varying both in shape and size. 
The mucous membrane is thickened and the submucous connective tis- 
sue is hypertrophied; the capillaries are dilated, in some instances being 
changed into cavities which contain full-grown specimens of the disto- 
ma. In the interior of these excrescences numerous ova are found. It is 
not surprising that an organism which infests the urinary tract of men 
should find its way into the vagina; and infections of that canal by this 
parasite are of occasional occurrence. The mucous membrane becomes 
greatly hypertrophied owing to papillomatous developments, the ex- 
crescences on the interior of the vagina being numerous and flat-topped, 
and divided by distinct depressions, while occasionally one of them may 
become large and pedunculated. The treatment consists in excising the 
excrescences, cauterizing their base, and treating the wounded surface 
with bichloride douches. It may be necessary, in removing the larger 
growths, to incise the mucous membrane so deeply as to render essential 
the closure of the wound by sutures. 

Chancroid, or soft chancre, is a local, contagious ulcer, which is 
not followed by infectious, constitutional symptoms. It occurs as 
the result of inoculation from another chancroid and is inflammatory 
in character, with destructive characteristics which never produce 
syphilitic or other systemic infection. It sometimes, however, causes 
inflammation of neighbouring lymphatic glands, resulting in their sup- 
puration — a condition called chancroidal bubo. It sometimes becomes 
serpiginous, spreading from its original place to the different parts 
of the pudendum, or even to the abdominal walls; or it may become 
very destructive, a condition designated phagedenic chancroid. Chan- 
croid is usually met with in the lowest class of society, where igno- 
rance and filth are found together. It is essentially a venereal dis- 
ease, as it is transmitted chiefly, if not exclusively, by the act of sexual 
intercourse. The secretion of the chancroid, or the pus of the chan- 
croidal bubo, is the carrier of the contagium. It has been demonstrated 
that the contagious germs of a soft chancre are contained in the 
lymphoid bodies or in the pus cells, inasmuch as the inoculation by 
filtered serum derived from these sources produces only negative results. 

One of the characteristics of chancroid is its self-inoculability, by 
which is meant that one surface primarily inoculated will, in turn, 
inoculate another surface with which it lies in contact. Immunity 
from such self-inoculation is never acquired. The communication of 
the infection from one surface to another requires the pre-existence 
of an abrasion, excoriation, or small fissure, through which the virus 
finds its entrance into the derma. In some cases the infectious ele- 
ment finds its way into the ducts of the excretory glands or into 
the hair follicles, producing round ulcers, called follicular ulcers, 
which indicate the channels through which the virus entered. Medi- 
ate contagion is more rare in chancroid than in syphilis. Any article, 
such as clothing or the seat of a water-closet soiled with purulent 
secretions from chancroids, it is said, may communicate the conta- 



182 A TEXT-BOOK OF GYNECOLOGY 

gion, but Eavogli has never met a case in which he could verify this 
theory. 

Soft chancres may be found in women primarily at the ostium 
vaginae, on the fourchette, the vestibule, the clitoris, the labia majora, 
the labia minora, the perineum, the inner surface of the thighs, the 
two lower quadrants of the abdomen, and around and within the 
margins of the anus; and they appear, secondarily, by self-infection, 
upon proximal surfaces, and wherever the infection may be carried 
to a break in the protecting epithelium. On the labia they are gen- 
erally associated with follicular abscesses, oedema, and frequently with 
extensive destruction of tissue. Purulent secretion drying upon the 
surface occasions an eczematous appearance. The terms exulcerous, 
follicular, acneform, eczematous, erythematous, serpiginous, and 
phagedenic, have been applied to chancroids to distinguish obvious 
physical or clinical characteristics. 

The prevalence of chancroids varies in different localities, being 
more common in cities on the seashore than in those inland; and they 
are more prevalent in the crowded quarters than in the less densely 
populated districts. Eobert W. Taylor states that the examination of 
the yuellce publicce revealed the greater prevalence of chancroids 
among the women of the lowest grades, while there was relatively a 
greater prevalence of hard chancre among prostitutes who were better 
conditioned. Eavogli states that relatively few cases of soft chancre 
occur, annually, in his service at the Cincinnati Hospital, while they 
are very rare in his private practice. He finds, also, that in private 
practice they are liable to be of the mixed type. After a few weeks, 
instead of cicatrizing they become hard and syphilis follows, and for 
this reason he is cautious in giving an early diagnosis, particularly 
in the case of young subjects. Eavogli does not accept the theory that 
chancroids may be the result of pus from any other form of ulcera- 
tion associated with lack of cleanliness; nor does he believe that 
chancroid is caused by syphilis; but he concedes the possibility of 
mixed infection. 

The course of an ordinary chancroid covers a period of from two 
to three weeks, the time, however, being influenced by the habits and 
treatment of the patient. Lack of cleanliness, walking, and alcoholic 
drinks, prolong the period. Tissue destruction is less extensive and 
less rapid on the skin than on the mucous membrane. After the 
chancroid reaches a certain point, there is manifested a spontaneous 
tendency to repair. The inflammatory halo begins to fade, the 
oedema disappears, the grayish pseudomembrane at the bottom of 
the ulcer sloughs off, revealing abundant healthy granulations. The 
purulent secretion becomes thicker and of good colour. A ring of 
epithelium forms round the edges of the sore, gradually encroaching 
upon its centre, until it disappears under a film of newly formed 
scar tissue. At this point, or, at least, when near recovery, these 
ulcers may redevelop, manifesting all their original symptoms, the 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 1$3 

relapse being caused by coitus, alcohol, or uncleanliness. The appar- 
ently healed ulcers may retain their contagiousness for a long time, 
and be capable of transmitting a disease. 

Bacteriology. — Ducrey discovered constant bacterial elements in 
chancroidal pus. He found in a series of inoculations of chancroid in 
man, that many microbes, originally in the pus, disappeared from it, 
but that a peculiar microbe remained constant and abundant so long- 
as the pus retained its virulence. His observations were supported 
by those of Unna, Kneftning, and others, all agreeing on the iden- 
tity of this micro-organism. Ducrey found it in chancroidal pus, and 
Unna detected it in the infected tissues. It is a rodlike bacillus, 
from 1.5 to 2 /x in length, and from 0.3 to 1 ft in breadth, with rounded 
ends. It has a tendency to form chains (strepto-bacillus) and to become 
agglomerated in masses. In the pus it occurs singly, but in the tissues 
it is always in chain form. It has been found almost constantly in 
chancroid: it is stained by carbolic-fuchsin, and by gentian violet, and 
is decolourized by Gram's method. Although it is a pus bacillus it is 
characteristic of soft chancre, because it has not been found under other 
conditions. 

Pathology. — Chancroidal virus begins its activity as soon as it finds 
an infection atrium, through which it gains access into the subepi- 
thelial layer; the ulceration on the surface of the skin appears later, 
but is more rapid in development on the vaginal mucosa. As a rule 
the virus manifests its activity by developing within from twenty-four to 
forty-eight hours a small pustule, surrounded by an intensely red inflam- 
matory halo. This stage, especially in the mucous membrane, is 
soon replaced by the characteristic ulceration, round or oval in 
shape, according to the conformation of the parts; thus, when de- 
veloped within a fold, it may take on a linear appearance, while on 
the inner aspects of the labia majora the ulcers may coalesce and be- 
come irregular. But wherever the chancroid occurs, or Avhatever its 
shape, the edges are sharply cut as if the disk could be readily 
punched out. The bottom of a chancroid is uneven, and, in the begin- 
ning, is covered with a kind of diphtheroid membrane consisting 
of necrotic tissue. The ulcer exudes abundant, thin, purulent secre- 
tion, sometimes of a rusty colour; the underlying cellular tissue is 
sometimes cedematous — particularly when the inflammation is intense, 
in which case the soft chancre manifests firmer consistence when 
taken between the fingers, which fact must not mislead the practi- 
tioner into mistaking the case for one of syphilis. 

The diagnosis of chancroids may be confusing in the earlier 
stages. They may then be mistaken for herpes, but the difference 
will be detectable by a careful examination of the lesions. Vesicles, 
a nonulcerated surface even when broken, smooth edges, and the 
coalescence of vesicles, are features of herpes. Sometimes chancroids 
are mistaken for syphilitic mucous patches; the development, size, in- 
duration, peculiar colour, elevation of the edges, and symptoms of 



184 A TEXT-BOOK OF GYNECOLOGY 

syphilis, will, however, enable physicians to distinguish between the 
two conditions. If doubt still remains, recourse may be had to the 
crucial test of self-inoculation. 

The prognosis of chancroids is less favourable in women than 
in men. The conformation of the parts, the difficulty of cleansing 
them and of retaining dressings, the presence of urine and of the 
menstrual fluid, are all barriers to a speedy cure. Suppurative adenitis 
or buboes prolong the treatment. Phagedena, fortunately rare, is 
generally promptly overcome. In cases occurring in drunkards of 
lowered vitality, a guarded prognosis should be given. 

The treatment, to be effective, must be based upon the principle 
of cleanliness. Eavogli secures this in his hospital service by having 
the parts washed three times a day with hydrogen peroxide, dusted 
with iodoform powder, and covered with iodoform gauze. Cure is 
generally very prompt and free from complications, no buboes having 
developed in his wards. In rapidly progressive chancroids, cauteri- 
zation by carbolic acid or nitric acid should be practised. The sur- 
face should be first rendered insensitive with a 5-per-cent solution 
of cocaine hydrochloride. Care should be taken to protect the neigh- 
bouring parts from the action of the caustics. The use of carbolic 
acid is followed by a little secretion, and is less painful than nitric 
acid which causes sharp inflammatory reaction. After cauterization 
the ulcer is treated like any other granulating surface. Iodoform in 
private practice is objectionable because of its odour. Iodol, europhen, 
bismuth subiodide, have all been tried and discarded by Eavogli, who 
still uses aristol but deems it inferior to iodoform. Gaylord has used 
with success a 10- to 40-per-cent solution of formalin as an escharotic. 
Strong applications of this kind, however, have been generally aban- 
doned since the advent of iodoform. A 6- to 8-per-cent solution of 
sulphate of copper stimulates granulation. If the ulcer is sluggish in 
healing, it may be curetted. A well-regulated diet, improved hygiene, 
stimulants and tonics, are indicated in old run-down cases. Opiates 
are sometimes needed for pain, although hot water containing a little 
potassium permanganate or mercury bichloride, used in compresses, 
may be sufficient to allay the pain and to change an unhealthy to a 
healthy surface. 

Hard chancres in women are very frequent, their course is irregu- 
lar, and their diagnosis sometimes difficult. In some cases the chancre 
is so small and ephemeral that it is often overlooked; in others it 
is very pronounced, but on account of the associated inflammatory 
conditions, its exact nature is more or less obscured. In women, the 
characteristic induration of chancre is less pronounced than in men; 
occasionally, when located around the fourchette, it produces a hard 
thick cicatrix which may last for many months. The examination 
of the genitalia in women is sometimes difficult on account of the 
conformation of the parts, although in all cases it should be made 
with thoroughness. Chancres may be single or multiple, only one 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 185 

being found in the majority of cases. For clinical purposes, chancres 
in women have been divided into (1) superficial or chancrous erosion; 
(2) scaling papule; (3) elevated papule, or ulcus elevatum; (4) incrusted 
chancre; (5) indurated nodules; (6) diffused exulcerated chancre. 

(1) Superficial, or chancrous erosion is the form most frequently 
met with in women. It is difficult to recognise in its earliest stages; 
it is always found on the surface of the mucous membrane, begin- 
ning as a red spot somewhat deeper in colour than the mucous mem- 
brane itself. It is liable to pass without notice, so that when first 
seen by the physician it is already deprived of its epithelium and 
manifests incipient ulceration. When it is seated on smooth sur- 
faces like the labia it is easily recognised, but when it is on the 
fourchette or within the ostium vaginae it is not easily discovered. The 
chancre is of red colour, round, with a smooth surface, from which 
oozes a thin serous secretion that assumes the appearance of true 
pus only in the presence of active inflammation. In these chancres, 
the induration is only superficial, of that kind which Fornia called 
chancre parchemine. The diagnosis of this form of chancre is not 
difficult when due attention is given to the foregoing appearances. The 
exact character of the trouble is established in the course of a few 
days when the lymphatic glands of the groin become involved. The 
course of this kind of chancre is rather short; it undergoes speedy 
involution, which accounts for the fact that constitutional symptoms 
of syphilis are manifested in some women in whom we are not able 
to find the initial sore. In many cases, however, after the disappear- 
ance of the chancre, there remains on the area that it occupied, a kind 
of red spot, very persistent, and lasting at times for months. This 
chancrous erosion, especially when located on the vulvar lips, produces 
a kind of chronic oedema of the underlying tissues, and sometimes 
of all the pudendal structures; it lasts frequently after the chancre 
has completely healed. When the primary ulcer is seated on the 
fourchette it assumes the typical induration of a hard chancre, pre- 
senting a raw-beef appearance characteristic of the initial syphilitic 
lesion. (2) The scaling papule may appear on the skin of the labia 
majora and of the labia minora as the initial syphilitic lesion. It 
is a small, dull-reddish papule, slightly elevated. It develops into 
an elevation of the skin, has a purplish brown colour, sharply 
defined edges, and in size varies from that of a split pea to that of 
a quarter of a dollar. It is round or oval according to the shape 
of the parts where it is located, and is firm, hard, and resistant to 
the touch. It is usually single, sometimes double, and gradually loses 
its epithelium, becoming ulcerated and incrusted, when it is called 
an ecthymatous chancre. (3) The elevated papule, or ulcus elevatum, 
begins as a chancrous erosion with hyperplastic infiltration, and grows 
to a considerable size. It is round or oval, deep red in colour, and 
has a smooth, velvety surface, flat or concave with distinctly elevated 
edges, and discharges a thin serous fluid. Irritation from walking 



186 A TEXT-BOOK OF GYNECOLOGY 

or from uncleanliness may provoke inflammation, causing a pro- 
nounced oedema of the labium on which it is seated. Careful pal- 
pation will reveal a slight induration, parchmentlike in character. This 
condition is essentially chronic, lasting many weeks, resolving slowly, 
leaving a deep red spot which is replaced by a scar. (4) Incrusted 
chancre affects the cutaneous surface of the pudendum, beginning as a 
chancrous erosion or as an indurated nodule, and speedily developing 
a kind of film of a light, greenish, creamy tint, or, at other times, 
of a brownish red necrotic character. (5) The indurated nodule is 
rather rare in women and is found where the skin and mucous mem- 
brane join each other. It manifests itself as a sharply circumscribed 
mass of indurated tissue with a narrow base and sloping edges. (6) 
The diffiused exulcerated chancre is found in women of the lower class; 
it begins as a chancrous erosion, grows to an ulcus elevatum, and 
then spreads over an extensive area. It has an ulcerated and un- 
even surface, deep red in colour, but only slightly painful, although 
frequently associated with oedema of the part on which it is developed. 

The bacterial origin of syphilis, although very probable, has not 
been demonstrated. The analogy between syphilis and other diseases of 
known bacterial origin prompts the belief that the various phenomena 
of the disease depend upon a bacillus, not yet isolated, and its toxines. 

The pathologic changes occurring in indurated chancre are of an 
inflammatory character, and are accompanied in any stage of syphilis 
with a persistent involvement of the blood vessels; an infiltration of 
small round cells associated with those of larger size, and polyhedral 
in form, occurs in the meshes of the connective tissue surrounding the 
blood vessels. There is a constant tendency to the production of new 
connective tissue, especially in the initial chancre, and again in the 
later tertiary stage as manifested in the nervous system. The peri- 
vascular changes and the infiltration of the tissues beyond the chancre 
are the most important features of the initial sore. The lymph spaces 
are readily affected with the peculiar infiltration, the virus speedily 
travelling through this channel to the inguinal glands. The peripheral 
perivascular lymph spaces are infected by the time the chancre makes 
its appearance; and the first halt in the march of the virus is shown 
by the swelling and induration of the inguinal glands. Microscopically, 
a well-developed chancre reveals a seminecrotic mass of small sphe- 
roidal cells which constitute the bulk of the ulcer, circumvallated by 
a zone of oedema and a cellular infiltration of the papillary layer of 
the derma. This oedema acts as a wall to protect the surrounding 
healthy tissues from invasion. The virus, having entered the lym- 
phatics, passes from one gland to another until it reaches the general 
circulation. This occurrence marks the transition from the secondary, 
or incubation period, and the disease breaks out in the ordinary form 
of roseola with all the accompanying symptoms of chlorosis, neuralgia, 
syphilitic fever, etc. 

The female genitals, like any other part of the integument, may 



— 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 1ST 

show ever)' kind of eruption which results from the two morbid pro- 
cesses of hypersemia and infiltration. The hyperemia is mostly found 
in the early period of syphilis in the erythematous syphilides; the 
infiltration is always more advanced in the later stages. In the early 
eruptions, however, a slight cell infiltration is always present, giving 
rise to patches and nodules. In this stage of syphilis, Eavogli has 
repeatedly found a kind of infiltration of the skin of the labia rnajora 
and labia minora, just at their free edges, showing the epidermis slightly 
abraded and intermingled with superficial erosions; besides this slight 
thickening of the skin, the patches show a kind of dirty yellowish 
colour, and are accompanied with itching. Mucous patches or con- 
dylomata lata, are quite often found on the external genitals of women, 
during the first two years of the course of syphilis; this eruption is 
characteristic of syphilis, and when discovered settles all doubt relative 
to the diagnosis. Mucous patches, on account of their abundant secre- 
tion, are the most dangerous eruption for the transmission of syphilis. 
Ravogli is of the opinion that most cases of syphilis are communicated 
by mucous patches. They are found on the mucous membranes and 
on proximal surfaces of the skin which are continually moistened by 
perspiration. They begin on the skin as flat elevations, circular or dis- 
coid in form, and of different sizes, showing a depression in the centre 
with elevated borders; the epidermis in the centre is macerated by 
the moisture and is transformed into a grayish pellicle. This is soon 
cast off, leaving a plaque of a raw flesh-coloured appearance. This 
plaque secretes abundant serum, which .soon becomes altered and 
causes an offensive smell, and by irritating the skin induces intertrigo. 
Eavogli has observed a kind of contagiousness in these patches, mani- 
fested by the development of similar lesions on proximal cutaneous 
or mucous surfaces. They assume a variety of appearances, accord- 
ing to location and the local conditions to which they are subjected. 
On account of the presence of urine, perspiration, etc., they may de- 
velop superficial ulceration, manifested by an abundance of offensive, 
purulent secretion. As a result of persistent irritation, the patches 
may become uneven with a verrucous aspect, caused by hypertrophy 
of the papilla? of the derma, a hypertrophy which sometimes assumes 
a vegetating character (condylomata lata). These different appearances 
of mucous patches have caused authors to classify them as diphtheroid, 
ulcerative, vegetative, or hypertrophic. They are either round or oval 
in shape, according to the part upon which they are located; some- 
times they appear like ulcerated rliagades around the ostium vagina? 
or between the anal folds. On the mucous membranes, mucous patches 
have a kind of grayish appearance with marked edges slightly ex- 
coriated in the centre. The chronological period of mucous patches 
is the secondary stage from its beginning to its end. Eavogli 
(Monatshefte fur prahtisclie Dermatologie, 1893) observes that it is not 
rare to see patches on the tongue and in the mouth of syphilitic 
patients after four or five years following the primary infection, and 



188 A TEXT-BOOK OF GYNECOLOGY 

in patients who are already manifesting tertiary symptoms. These 
lesions are sometimes the most stubborn manifestations of syphilis, as 
they show a tendency to frequent recurrence. When not properly 
treated, they may become hypertrophic, forming papillomatous masses 
which may persist for a long time. They usually disappear by a pro- 
cess of superficial ulceration and without leaving a scar. The anatomo- 
pathologic lesions of mucous patches consist in hypertrophy of the 
papillae, and in abundant infiltration of cells throughout the papil- 
lary layer and the corium. The mucous layer of the epidermis is 
also affected, showing a proliferation of the cells, and a granular 
change of their protoplasm that gives to the cells a peculiar appear- 
ance. In the ulcerated patches this becomes obscure. On account 
of the dusky appearance of the infiltrated papillae, the mucous layer 
in many points being absent, and the tips of the papillae mutilated by 
the ulcerative process, mucous patches when once seen and identified 
will always be recognised. There can be no doubt that they are an 
exclusive form of constitutional syphilis. 

We have already spoken of the acuminated condylomata, which are 
nonsyphilitic manifestations, and we have pointed out the charac- 
teristics which distinguish them from the condylomata, or mucous 
patches. It is possible to make a mistake only in cases of hypertrophic 
or vegetative mucous patches, but the absence of the pedicles, the 
characteristic ulceration, the abundant sero-purulent secretion, and 
the accompanying antisyphilitic symptoms, should be sufficient points 
of difference to establish the true diagnosis. 

Treatment. — It is beyond doubt that in order properly to treat 
mucous patches, a general antisyphilitic treatment must be adminis- 
tered. The choice of the antisyphilitic remedies is subject to the con- 
dition of the patient, to the period of syphilis, and so forth: and it 
would be entirely out of place to enter here into such a difficult and 
intricate question. The mucous patches require local treatment. 
Local treatment in a great many cases consists in the observance of 
the rules of cleanliness. The best treatment, in Eavogli's opinion, for 
mucous patches, is to wash the surface well with an antisyphilitic 
solution of mercury bichloride, 1 to 2,000, and, after a while, to dry 
and powder them with calomel. In some cases the mucous patches 
are extremely stubborn, with a tendency to ulceration and hypertrophy, 
and in these cases it is necessary to use caustics. The application 
of a 4-per-cent solution of acid nitrate of mercury produces a super- 
ficial cauterization, and we may be sure that after touching the 
mucous patches two or three times with this solution they will readily 
heal. Sometimes the mucous patches resist the application of the 
solution of acid nitrate of mercury, and in these cases it is necessary 
to resort to stronger caustics; then, nitric acid in full strength is 
useful for the destruction of these patches. The application of salves 
or plasters to mucous patches is not to be recommended, because they 
are found where the skin forms folds and is macerated by the per- 



INFECTIONS OF THE EXTERNAL GENITAL ORGANS 189 

spiraticn; it is better, therefore, to use antiseptic bathing and the 
application of dry powder, which will prevent the accumulation of 
the perspiration. 

Late Syphilitic Ulcers of the Female Genitals. — Syphilitic ulcers 
of the vulva were studied in 1849 by Huguier, in his article on JEsthio- 
mene, or Dartre Rongeante de la region vulvo anale, Paris, 1849, and 
by Matthews Duncan in the Edinburgh Medical Journal, July, 1884. 
In the venereal ward of the Cincinnati Hospital, Eavogli has had 
occasion to observe a great many cases of extensive and deep ulcers 
of the vulva in dissolute women who have been admitted into that 
institution. He supports the opinion of Hyde in denying that those 
ulcers of the vulva have anything to do with lupus vulgaris, and thinks 
that there can be no doubt that the women have been affected with 
syphilis. He admits that the extreme destruction of the external geni- 
tals of women which are occasionally observed may be due, not to 
syphilis alone, but probably to syphilis in connection with tuberculosis; 
and he remembers one case in his service in which a large and deep 
ulcer had destroyed part of the labia minora and part of the entrance 
of the vagina. The woman died, and at the post-mortem the peri- 
neum was found to be studded with tubercles. Usually, these ulcers 
are found in weak patients, with a system run down from misery 
and debauchery. The ulcers are always seated on a strong and thick 
induration which is confined to one or both labia. This infiltration 
sometimes extends to the mons veneris, and may also spread downward 
to the perineal tissues. It is accompanied by a kind of hypertrophy 
which is felt deeply situated in all the tissues. On these indurated 
places, ulcers are found which are deep and destructive. One or both 
labia may be destroyed. Sometimes, when the ulceration affects the 
perineum, the destruction may extend to the anus producing altera- 
tion of its function. The edges of these ulcers slope to the bottom, 
which is red or grayish from necrotic detritus, without a tendency 
to the formation of healthy granulations. The destruction once begun 
goes on very rapidly, and it is a difficult task to stop its ravages. Says 
Eavogli: " In my experience I have found this form of vulvar syphilitic 
ulcers more frequent in the negro race than in the white race. The 
date of infection from syphilis was from six to twelve years. No 
enlarged glands could be found in the groins or in the cervical region, 
yet, in many of these women, deep scars could be found on the legs, 
witnesses of progressed gummata, and roughness of the tibia could 
be found, showing progressed specific periostitis. These ulcers are 
the result of late syphilis. They are the result of gummatous infil- 
tration, but there is no doubt that the general condition of these 
patients has a great deal to do with the virulence of syphilis." 

The prognosis of these ulcers must be given with great reserve. 
There are two principal elements for the production of the ulcers: 
First, advanced malignant syphilis; secondly, weakness of the general 
system. 



190 A TEXT-BOOK OF GYNECOLOGY 

The treatment consists, first, in improving the general system with 
good diet, tonics, and better surroundings. Antisyphilitic treatment 
consists mostly in the administration of potassium or sodium iodide. 
Mercurials can scarcely be recommended on account of the weak and 
poor condition of the patients. Beneficial results follow applications 
of a solution of mercury bichloride, 1 to 2,000, and then covering 
the ulcerated and infiltrated surface with the emplastrum hydrargyri, 
which, producing an abundant suppuration, in a short time causes a 
sloughing out of all the detritus from the bottom of the ulcers. In 
the same way, the application of the emplastrum hydrargyri helps a 
great deal toward the absorption of the infiltration and oedema which 
form the base of these vulvar syphilitic ulcers. The washing with 
peroxide of hydrogen and the application of powdered iodoform have 
also given very good results, but only in later stages, when the em- 
plastrum hydrargyri had already diminished the infiltration. The 
curette has been used in cases where the surface has been covered 
with abundant ill-natured granulations. But with this exception, 
there is but little need for the curetting of such ulcers. The applica- 
tion of strong caustics, such as nitric acid and the actual cautery, 
has been tried only in those cases in which the destructive process 
had taken wide proportions. It is seldom necessary to resort to these 
means, particularly when good results are realized by the emplastrum 
hydrargyri. 



CHAPTER XVII 

DISEASES OF THE SKIN OF THE FEMALE GENITALS 

Intertrigo — Erythema — (Edema — Eczema — Folliculitis — Herpes progenitalis — Pru- 
ritus — Parasitic affections — Atrophy (Kraurosis) — Vulvar adhesions. 

The skin of the genitals of the woman is subject to all the diseases 
that are met with in the general integument, and, on account of their 
anatomical structure and position, some affections are more frequently 
found here than in other regions. 

Intertrigo. — This common affection is usually found in fleshy 
women. It is produced by the apposition of the surfaces of the skin of 
the thighs with each other and with the external portion of the labia 
majora, and is a result of friction. Under these circumstances perspira- 
tion is very abundant, and it macerates the epidermis and causes an 
inflammation of the skin, which in the beginning is limited to the de- 
gree of a simple erythema, but, continuing, reaches the degree of a true 
eczema. Indeed, in the beginning, the surface of the inguino-crural 
fold and of the labia is red and moist, and the epidermis appears slightly 
macerated. An itching and burning sensation is associated with the 
affection. If promptly treated the skin returns to the normal condition 
in a short time. If the affection is allowed to continue, then, on account 
of the profuse perspiration and of its chemical changes, associated with 
impurities and uncleanliness, the epidermis is deeply macerated, the sur- 
face is excoriated, oozing a serum which starches the linen, and the 
patient can scarcely move on account of the pain produced by the 
motion on the inflamed skin. Although the affection is called eczema 
intertrigo, Eavogii does not consider it a true eczema. Eczema may be 
the consequence of the intertrigo, just as it may follow any other irrita- 
tion of the skin. 

Vulvar intertrigo is caused by gonorrhoea, syphilis, or the accumula- 
tion of nonspecific but irritating secretions, in the cutaneous folds of 
the pudenda and groins. The large quantity of sero-purulent secre- 
tion oozing out of the vagina in cases of gonorrhoea, moistens the skin 
of the genitals and of the thighs, and by its irritating qualities causes 
intertriginous eruption. This intertrigo is also found in patients who 
observe strict cleanliness. In women neglectful of the principles of 
hygiene the intertrigo assumes a much more aggravated form. In 
the first case the affection is limited to the front part of the genitals, 
labia majora, labia minora, and clitoris with its prepuce, as a result of 

191 



192 A TEXT-BOOK OF GYNECOLOGY 

the contact of the gonorrhoea! fluid on the skin. In the second case in- 
tertrigo is spread more on the internal surface of the thighs and of the 
labia majora in the fossa genito-cruralis, in consequence, not merely of 
the presence of the purulent secretion, but also of the friction of the two 
surfaces of the skin, which become macerated by the purulent secretion, 
perspiration, and other impurities. Intertrigo in these cases is acute, 
the surface of the affected skin is red and somewhat swollen; the 
epidermis is macerated, giving it a whitish, soggy appearance; abrasions 
and small rhagades are formed on the labia majora, in an oblique direc- 
tion toward the fossa genito-cruralis; the surface is always moist from 
the discharge of serum, which, together with the gonorrhoeal secretion 
and the perspiration, produces an offensive smell. A burning sensation 
accompanies the course of the affection, and motion makes it so painful 
that the woman can scarcely walk. 

Another form of intertrigo, more chronic in form but occurring 
under the same circumstances, was recently described by L. Brocq and 
Leon Bernard (Annates de dermatologie et de syphiligraphie, 1899, 
fasc. 1, 3). It is limited to the genito-crural fossa, and when the woman 
is placed in the position used for the speculum examination, it appears 
like a triangle with the base at the fossa and the apex downward on the 
upper lateral side of the thighs. The skin is of an intensely dark-red 
colour, showing deep furrows in an oblique direction, and between them 
follicles can be seen. The pigmentation is very deep, due partly to the 
inflammatory process and partly to the chromatogenous condition of 
these regions. A kind of small, flat, papillary growth can be seen on 
the surface like a lichenization, which is due to a proliferation of the 
connective tissues in the papillae with some hypertrophy of the epider- 
mic layers. 

The pathology of this affection is limited to the epidermis and to the 
superficial layer of the derma. They are the same as are found in 
any other inflammatory disease of the skin, hyperaemia, overfilling of 
the blood vessels, which is the cause of the inflammatory redness, and 
swelling. In consequence, after increased pressure in the blood vessels, 
some exudation of serum and of the white corpuscles of the blood takes 
place through the walls of the blood vessels. The small round inflam- 
matory cells and the white corpuscles of the blood infiltrate the papil- 
lary layer, and so increase the nutrition of their connective tissues. 
The epidermic cells are macerated by the presence of the exudation, and 
the horny lajer is easily detached by the other epidermic layers, and in 
this wajr excoriations are formed. On the other hand, when the inflam- 
matory process lasts for a long time the papillae become infiltrated with 
cells, and their connective-tissue corpuscles may increase in their nutri- 
tion and proliferate, producing small flat papillary warts as a conse- 
quence of the irritation. 

The diagnosis of intertrigo by pathologic alterations from eczema 
and dermatitis is an impossibility. Eavogli, in reply to the ques- 
tion whether this affection, being of an inflammatory character, is 



DISEASES OF THE SKIN OF THE FEMALE GENITALS 193 

to be classified as an eczema or a dermatitis, replies: It is a question of 
degree; it progresses from a pale rose-red colour to a deep reddish-violet 
colour. From a scarcely perceptible swelling it may attain a thick and 
pronounced (Edematous condition, and in the same way there can be a 
thin, serous, scanty discharge, while in other cases an abundant, copious 
discharge exudes, which wets the linen of the patient. He believes, 
therefore, that the name intertrigo is well adapted. It gives the idea of 
the affection as the result of the friction of two cutaneous surfaces, and 
of the possibility of curing it in a short time by preventing the contact 
of the cutaneous surface. It is of a rather peculiar nature and has to 
be referred to dermatitis. Intertrigo is also found in syphilitic women, 
often accompanying the presence of mucous patches in the secondary 
stage. The secretion oozing from syphilitic eruptions, which in that re- 
gion usually are ulcerated, causes the maceration of the epidermis, and 
intertrigo is the result. In these cases the first thing to do is to treat 
the mucous patches, and with cleanliness the intertrigo easily disappears. 

In the same way, for the intertrigo accompanying an acute gonor- 
rhoea, the first indication is to treat the gonorrhoea and prevent the gon- 
orrheal fluid from remaining on the skin of the external genitals. Al- 
though cleanliness may be maintained, and the improvement of the 
acute gonorrhoea be effected, yet the intertrigo left to itself will not 
heal, and it requires some attention and some local applications in 
order to bring about recovery. 

Treatment. — In intertrigo cleanliness must be observed, so as to re- 
move all impurities from the irritated surfaces of the skin. After wash- 
ing and drying, the surface is covered with rice powder or starch pow- 
der, to which may be added a small quantity of boric or salicylic acid 
(2 to 100). 

When the epidermis is excoriated, the surface is sore and there is 
a great deal of serous secretion. Eavogli finds of great advantage the 
use of bathing with some astringent solution. The solution of sub- 
acetate of aluminum and lead, known as Burow's solution, 3 per cent, 
applied on lint, in order to separate the skin surfaces from each other, 
is very beneficial. If the patient can remain in bed, with a few appli- 
cations of this solution the intertrigo will easily disappear; but if the 
patient must attend to her occupations, then bathing may take place 
morning and evening, and during the day some salve may be applied, 
such as Wilson's ointment, or an ointment of — 

I£ Zinci oxidi, ) __ ,_ 

Bismuthi subcarbonatis, f 

Acidi carbolici gtt. x; 

Vaselini gj. 

M. Fiat unguentum. 

This can be rubbed on the surface, and particularly upon the labia 
majora, which should be kept separated from the thighs by means of 
soft lint. 

14 



194 A TEXT-BOOK OF GYNECOLOGY 

In chronic intertrigo with papillary hypertrophy it is necessary to 
use more active remedies. Two or three applications of Wilkinson's 
ointment — 

1^ Sulphuris sublimati, ) 

Picis liquidae, > aa, 3vj; 

Saponis viridis, ) 

Terrae albae 3iij; 

Aclipis suis gj. 

M. Fiat unguentum. 

have given good results, for by causing the desquamation of the old 
epidermis we obtain a new soft epidermis. The application of a re- 
sorcin salve can also be recommended. 

IJ Eesorcini 3ss.; 

Acidi salicylici gr. vj; 

Vaselini flavi §j. 

M. Fiat unguentum. 

When the epidermis has returned to its normal condition and the 
serous secretion has stopped, the only way to finish the treatment and 
prevent any relapses is to use scrupulous cleanliness, and after washing, 
to dust the genitals and genito-crural region with one of the recom- 
mended dusting powders. 

Erythema. — The skin of the genitals of the woman is often the seat 
of erythema, the result of various causes. Obstinate erythema affects 
the female genitals in consequence of glycosuria, and indeed it is the 
duty of the physician when he finds cases of erythema localized in the 
genitals to examine the urine. In these cases the labia minora are red 
and slightly swollen, the labia majora are red and swollen, the colour 
is rose-red, of an intense hue, and the epidermis, distended from the 
scanty exudation of serum, takes on a smooth, silky, and glossy appear- 
ance. This erythema sometimes spreads to the internal surface of the 
thighs, but in the usual eases it remains limited to the genitals. Ex- 
coriations are found on the reddened and swollen surface of the skin, 
produced by the act of scratching, because this glycosuric erythema 
is often accompanied by a persistent itching sensation — pruritus vulvae. 
Pruritius is in these cases very intense, and the patient can not restrain 
herself from scratching in order to stop this disagreeable itching sensa- 
tion. This deprives the sufferers of their sleep at night, and the con- 
stant scratching irritates the skin so much that it produces a persistent 
oedema or pustules, and superficial ulcerations. 

The presence of sugar in the urine, moistening the mucous mem- 
brane and the skin of the genitals, is the cause of the erythema. - It 
must not be forgotten, however, that the tissues of glycosuric persons 
offer a good ground for the development of the pus germs, and as a 
result they are often troubled with persistent furunculosis. 



DISEASES OF THE SKIN OF THE FEMALE GENITALS 195 

Treatment. — Although it is difficult to cure this erythema on ac- 
count of its persistent cause, yet great benefit can be obtained from 
general and local treatment. For the first object, it is necessary to sub- 
ject the patient to the ordinary diet of diabetics, by forbidding all amy- 
laceous food and thus diminishing the quantity of sugar in the urine. 
These dietetic rules must be accompanied by the use of some mild 
purgative mineral waters, like Carlsbad, Apenta, Hunyadi Janos, Blue 
Lick, Congress, etc., taken regularly every morning in a dose of from 
half a glass to one glass, according to the tolerance of the patient. For 
local treatment the most important rule to follow is cleanliness. The 
external genitalia and the vagina are to be thoroughly washed with 
green soap and water and then irrigated with a 2-per-cent solution of 
carbolic acid. The patient is advised to remain in bed and apply com- 
presses with liniment of oil and limewater, to which may be added from 
2 to 4 per cent of ichthyol. When the patient gets up she may make 
an application of Wilson's salve or the suggested formula of oxide of 
zinc and subcarbonate of bismuth. Lassar recommends the following 
formula : 

~Ep Acidi phenylici 1 to 2 parts; 

Hydrargyri sulphidi rubri 1 part; 

Sulphuris sublimati 25 parts; 

Vaselini Americani 100 " 

Olei bergamottee gtt. xxx. 

M. Fiat unguentum. 

This mixture, as it contains a great quantity of sulphur, without 
causing irritation prevents the development of the pus germs which 
so often occur in the skin of diabetic persons. 

(Edema of the vulva may depend upon any of the conditions that 
interfere with the free circulation of the blood in the vulva, only a few 
of which are here considered. In cases of oedema of the legs as a con- 
sequence of heart disease or of general anasarca, the skin of the geni- 
tals of the woman is oedematous, swollen, of a waxy rose-red colour, 
the labia majora protrude in a round shape, and are sometimes painful 
on account of the acute distention of the skin. The labia minora and 
the clitoris are also swollen, presenting the same appearance; the 
thighs, which are also in an oedematous condition, do not permit the 
woman to bring the legs close together. There are, however, cases of 
oedema localized in the genitals of the woman of angioneurotic ori- 
gin, as described by Quincke, Jamison, and others. This oedema comes 
in the form of repeated attacks, which are often preceded by general 
malaise, vomiting, or diarrhoea. (Edema occurs in the form of a local- 
ized swelling of a whitish waxy rose-colour, with a certain brillianc}^ of 
the affected skin; it appears in different regions of the body, and the 
genitals may be included. Eavogli has observed a woman subject to 
attacks of this affection which could with propriety be called the giant 
urticaria of Wilson. The swelling in this case was limited to the 



196 A TEXT-BOOK OF GYNECOLOGY 

right labium, assuming the size of a fist, and it was accompanied by 
some pain and an itching sensation. It lasted for several hours and 
then gradually disappeared without leaving any trace. It is easy to 
understand that the swelling was due to an effusion of serum in the 
meshes of the connective tissues of the derma and of the subcutaneous 
tissue, and that the acute oedema was the result of an angeioneurotic 
affection, as the patient had frequently had similar localized oedema 
on half of her face and on her left shoulder. 

(Edema of the vulva as a result of passive hyperemia has been ob- 
served by Eavogli, in the practice of Fackler, in a case of Eaynaud's 
disease. One of the labia majora was bluish, red, and swollen, with a 
sloughing patch of superficial gangrene, together with the same as- 
phyctic symptoms in several toes. 

(Edema accompanied by stasis sometimes appears in one labium 
on account of a hard chancre concealed in the internal surface of 
the labium or in one side of the ostium vaginae. In this case oedema 
affects only one labium, which is of a bluish-red hue, showing the 
location of the obstacle to the circulation. It is scarcely necessary 
to say that as soon as the chancre begins to heal up the oedema dis- 
appears. 

Treatment. — In cases of oedema of the genitals accompanying ana- 
sarca, the treatment has to be directed to relieve the general condition, 
but the local disturbance must not be neglected. The application, in 
the form of compresses, of mild astringent solutions, like Burow's solu- 
tion in a strength of 3 per cent, or Goulard's lotion, has been found 
very beneficial. In the same way, when stopping the application of 
the compresses, the use of dusting powder, as starch or rice powder, 
with the addition of 3 per cent of boric or salicylic acid, is found 
of great service. The nurse should apply soft linen pieces between 
the folds of the skin, thus preventing the surfaces from rubbing each 
other and causing intertrigo, which often complicates oedema of the 
vulva. 

Eczema of the Vulva. — Like any other part of the body, the skin of 
the female genitals is subject to eczema in acute and chronic forms. 
In speaking of intertrigo it was mentioned that, in consequence of the 
neglect of care and cleanliness, it may be the starting point of an 
eczema. In the same way, in cases of pruritus vulvae, the irritation 
caused on the skin by the continuous rubbing and scratching may be 
the direct cause of eczema of this region. The propagation of the 
Staphylococcus pyogenes aTbus on the deeper layers of the skin is to be 
recognised as the chief causative factor. 

Acute eczema may affect the vulva, implicating the labia majora and 
minora, clitoris, and the mucous membrane of the vagina, spreading 
along the periphery to the upper portion of the thighs. Along with the 
burning and itching sensation, a diffused redness and swelling affects 
the parts mentioned, and presently small vesicles appear, which soon 
break, causing a discharge of serum, which moistens the linen. 



DISEASES OF THE SKIN OP THE FEMALE GEXITALS 197 

Chronic eczema, however, is the form more often met with when 
localized upon the female genitals. It often occurs in the form of ec- 
zema rubrum, affecting the labia majora, labia minora, and the mucous 
membrane of the vagina. The labia majora are red, swollen, and infil- 
trated, and, in consequence, the rima vulvae is opened by the distention 
of the labia. On account of the unbearable itching sensation numerous 
excoriations are produced by the action of scratching and rubbing. In 
many cases the eczema spreads to the upper portion of the thighs and 
also to the mons veneris. On account of the spreading of the affec- 
tion to the vagina, an abundant secretion oozes out of the genitals, 
which increases the intensity of the affection. In order to be sure that 
the secretion is not of a venereal origin, Eavogli always makes a micro- 
scopic examination of it so as to exclude the possibility of the existence 
of gonorrhoea. 

Eczema of the vulva may, by continuity, very easily spread to the 
perineum and to the anus. The parts are red, thick, and excoriated, 
and serum oozes from the excoriations. Sometimes the excoriations 
are covered with crusts, but where there are opposing surfaces these 
become more or less glued. At other times no discharge takes place; 
the skin is rough, dry, and slightly scaly. It is always accompanied by 
a violent itching sensation, which causes great misery. This form of 
eczema may be the result of a local irritation, leucorrhcea and gonor- 
rhoea being the most effective factors; or it may be the result of the 
scratching and tearing of the skin incident to intertrigo. It may also 
be of reflex origin, or it may be referable to the presence of uterine dis- 
orders. 

Treatment. — Eavogli has always obtained good results by the appli- 
cation of ichthyol in different formulae. First, care has to be taken to 
improve the condition of the vagina by means of irrigations with a 
solution of biborate of sodium, which the patient will repeat twice a 
day. Every other day Eavogli inserts into the vagina a tampon satu- 
rated with a mixture of 25-per-cent ichthyol in vaseline or glyc- 
erine, which the patient will leave in the vagina for twelve hours. Ex- 
ternally he directs the patient to apply for a few minutes a solution of 
carbolic acid, which relieves the itching sensation and sterilizes the 
affected skin. The formula which he employs is: 

1^ Acidi carbolici oj; 

Glycerini 5ij ; 

Alcoholis §ij; 

Aquae rosae giv. 

M. Fiat linimentum. 

At first the patient complains of some burning sensation, but she is 
soon willing to repeat the application for the relief which it affords to 
the itching. After this application the patient is directed to apply 
pieces of lint well saturated with the following liniment: 



198 A TEXT-BOOK OF GYNECOLOGY 

^ Ichthyolis 3ij; 

Olei amygdalae dulcis, | __ _. 

a i- /■ aa t)ivi 

Aquae calcis, ) 

Glycerini, 

Aquae ros; 

M. Fiat linimentum. 



. aa 51. 
Aquae rosae, ' 



The use of salves is to be avoided in this condition, because the 
abundant secretion, together with the salve, makes rather an irritant 
mixture. 

After the repeated applications of the ichthyol liniment in the 
manner described, the surface of the skin begins to heal up, the itching 
sensation greatly diminishes, the swelling and the redness nearly sub- 
side, and at this point there may be applied a salve of oxide of zinc, 
which will finish the treatment. The formula for this salve is: 

I£ Zinci oxidi, ) _ r - . 

Bismuthi subcarbonatis, j 

Acidi carbolici gtt. x; 

Vaselini flavi §j. 

M. Fiat unguentum. 

When the skin has returned to its normal condition it will retain 
some redness as the result of the past trouble, for the relief of which 
Ravogli advises the patient to continue the use of the lotion of carbolic 
acid twice a day, and, after drying the surface, to dust the skin with 
an innocent powder, as starch or rice powder, to which some oxide of 
zinc or subcarbonate of bismuth may be added. 

Folliculitis. — Either in consequence of an eczema or without a 
known cause, an inflammatory process may invade the follicles of the 
hairs which cover the female genitals. The affection is rather rare, 
as Ravogli has met with this condition in only two cases, where the 
female genitals presented the exact appearance of sycosis. It is an in- 
flammatory affection in a subacute or chronic form, affecting the con- 
nective tissue of the hair follicles and also of the sebaceous glands 
connected with them. 

Bacteriological studies have recently explained that, like sycosis 
of the beard, folliculitis may be of double origin, either the result of the 
fungus of the ringworm or the result of the development of the pus 
germs in the follicle of the hair. In both cases which Ravogli had occa- 
sion to study, the pus cocci were the cause of the disease. In both cases 
the affection started from a superficial eczema and had developed until 
the surface gradually became covered with pustules, conical in shape, 
each one having a hair in the middle. 

It is easy to understand how the pus germs find their way into the 
follicles of the hair. The opening from which the hair passes through 
the epidermis is lined with epidermic cells, forming a kind of funnel 
around the shaft of the hair. According to Bockhart, the pus germs 



DISEASES OF THE SKIN OF THE FEMALE GENITALS 199 

capable of producing this affection are the Staphylococcus albus, 
aureus, and citreus, the same that can produce impetigo and furun- 
culosis. On account of an inflammatory process, especially eczema, the 
germs find the follicular openings more easy of access than in the nor- 
mal condition, and insinuate themselves into the follicles, thus causing 
inflammation of the tissues forming the follicle of the hair, and of the 
surrounding tissues. It will be seen that this is nothing more than a 
spreading of the process by continuity, when it is remembered that 
eczema is only the result of the production and development of the 
Staphylococcus pyogenes albus in the layers of the epidermis. 

The hair follicle, inflamed and swollen, is converted into a small 
abscess, as proved by Wertheim. A transudation of serum and white 
corpuscles of the blood takes place in the hair follicle, producing a 
hydropic condition of the membranes covering the root of the hair. 
The root is softened and swollen by sero-purulent infiltration, and in 
consequence the hair is easily removed, having no adherence. The 
papilla is usually spared from destruction, and this is the reason why 
in all cases of sycosis the hair is easily reproduced. 

Symptoms. — As in ordinary cases of sycosis, the folliculitis of the 
female genitals is revealed by the presence of pustules or papulo-pus- 
tules, each one being perforated by a hair. The pustules are conical 
in shape and contain a drop of pus at the point surrounding the shaft 
of the hair. The skin of the labia majora and of the mons veneris, 
when affected with folliculitis, is usually red and inflamed. This is 
accompanied by a burning and itching sensation. This affection is 
often associated with boils in the same region or in the neighbouring 
parts of the thighs or abdomen, caused by the inoculation with the 
staphylococci effected by the finger nails in the act of scratching. This 
affection of the follicles of the hair of the woman's genitals, although 
chronic and obstinate, is not so difficult to treat as sycosis of the beard. 
It may be said that without the necessity of removing the hair, either 
by shaving or by epilation, this disease can easily be treated, yielding 
readily in a few weeks to the action of remedies. 

Treatment. — Of course the general system should not be neglected, 
although the disease is a local one. The condition of resistance of the 
organism to the development of the pus germs is very important, and 
when we begin the treatment it is necessary to establish a plan of gen- 
eral medication. If the patient is in an anaemic condition, prescribe 
ferruginous and tonic preparations; if she is suffering from a scrofulous 
condition, the use of cod-liver oil will be of great advantage. In case 
the woman is inclined to gout, or if she perspires a great deal, we must 
prescribe anti-gout remedies, such as lithia, salol, salicylates, etc. 

The local treatment consists in enforcing rules of cleanliness. 
Ravogli uses with good results an application of compresses well satu- 
rated in an astringent and antiseptic solution, and frequently repeated; 
also compresses saturated with a mild solution of bichloride of mer- 
cury (1 to 1,000) for half an hour twice a day, followed by the applica- 



200 A TEXT-BOOK OF GYNECOLOGY 

tion of a salve, such as Wilson's ointment. In more stubborn cases the 
following formula can be used with good results: 

If Acidi carbolici gr. v; 

Bismuthi subnitratis oss.; 

Unguenti hydrargyri ammoniati oij ; 

Unguenti aquae rosse 5iv. 

M. Fiat unguentum. 

The application of ichythol is highly recommended. This is used 
in liniment form applied on lint, or in the form of salve, 10 per cent, 
in association with zinc ointment and 2 per cent beta-naphthol. 

Salves containing sulphur, from 4 to 6 per cent, are also found 
very useful. It can be applied in the form of Lassar's paste : 

I£ Sulphuris sublimati, ) 

Zinci oxidi, I aa 5j ; 

Amyli oryzse, ) 

Acidi salicylici gr. x; 

Vaselini §j. 

M. 

With this treatment and without any necessity of epilating, as in 
the case of sycosis of the beard, we can obtain good results in a short 
time. 

Herpes Progenitalis. — An eruption of vesicles disposed in groups, in 
an acute form, is often found on the genitals of women. It corresponds 
to the herpes preputialis which, with the same frequency, occurs in 
the male sex. This eruption appears on the internal surface of the 
labia majora, on the labia minora, on the vestibule and prepuce of the 
clitoris, at the orifice of the urethra, occasionally on the external sur- 
face of the labia majora, and at times it spreads to the mons veneris. 
Eavogli has twice seen groups of vesicles on the cervix uteri, corre- 
sponding with the observations of Bergh (tlber Herpes Menstrualis, 
Monatshefte fur Praktisclie Dermatologie, 1890), who has seen similar 
eruptions, sometimes accompanied by herpes of the vulva. 

Before the outbreak of the vesicles there are in most cases slight 
burning and itching sensations. Only rarely is the itching very pro- 
nounced, and it accompanies the course of the affection. 

The eruption consists of a single vesicle, or of a group of vesicles 
closely arranged, or of vesicles scattered on the surface following the 
ramification of a nerve. It begins as a red patch, which in a few hours 
shows vesicles. These are usually small, from the size of a pinhead to 
that of a hempseed, round, transparent, containing clear serum. When 
affecting the mucous membrane, on account of the succulence and the 
thinness of the epithelium they soon break, while on the skin they re- 
main longer. Their contents become turbid and soon form brownish- 
yellow crusts. 



DISEASES OF THE SKIN OF THE FEMALE GENITALS 201 

When the herpes is seated on the labia minora it may cause oedema 
of these parts, on account of the tenderness and laxity of their tissues. 
The vesicles when broken leave a superficial exulceration corresponding 
to the size of the vesicle. The bottom is of a rose-red colour, some- 
times covered with yellow detritus, with the edges cleanly cut, but not 
deep, and never as in chancroid. They are usually arranged in a group, 
and when broken the remaining exulcerations coalesce into one patch 
with festooned edges, reminding one of the round pre-existing vesicles. 
The vesicles are seated on an inflammatory base and heal up usually in 
a few days; in some cases they are persistent; in rare cases they become 
ulcerated, and it is difficult to distinguish them from a chancroid. Un- 
cleanliness and the presence of gonorrhoeal fluid sometimes irritate the 
resulting exulcerations of the vesicles and make them persistent. 
Herpes is inclined to relapse at different intervals, but relapses in women 
are not so frequent as in men. 

The causes of herpes progenitalis are difficult to determine. Usu- 
ally this affection is the consequence of an irritation or congestion of 
the sexual organs. In neurotic women it is found in connection with 
menstruation, so that nearly every month it is reproduced. In puellce 
publico? cases of herpes progenitalis are often met with on account of 
frequent and forced coitus, and also on account of disproportion of the 
parts. Herpes often appears in cases of gonorrhoeal inflammation of 
the female genitals, and is often the result of endometritis, salpingitis, 
and oophoritis. It may be considered as an abortive zoster, proceeding 
from irritation and the nervous ramifications of the pudenda, and some- 
times it shows this clearly by the disposition of the eruptive patches. 

Although herpes progenitalis has been often suspected to be the 
result of the presence of cocci, yet so far there is nothing positive in 
this regard. Eohrer (Monatshefte fur Praktische Dermatologie, 1888) 
found very few diplococci in the serum of the vesicles, and Pfeiffer 
(ibid., 1887) in a case of menstrual herpes could not find any micro- 
organisms. 

The diagnosis of herpes progenitalis is easily made if the vesicles are 
still present. When, however, the vesicles are broken and an ulceration 
remains, there may be some difficulty in distinguishing herpes from 
venereal or syphilitic ulcerations. The superficial character of the 
lesion, the scanty serous secretion, the peculiar round disposition of 
the edges, the smoothness of the surface, are characteristics enough to 
show us that we have to do with a case of herpes. Sometimes, however, 
a hard chancre in its erosive stage has been mistaken for herpes. (See 
Syphilis of the Vulva). In women, in whom, especially, the hardness 
of the lesion is often not clear, we lack one of the most important char- 
acteristics for diagnosis. The surface of a chancrous erosion is usually 
deeper in colour, round in shape, with a smooth surface, and is found 
in places where the herpes does not usually appear, as in the fourchette 
and in the ostium vaginae. 

With reference to the possible confusion of herpes with chancroid, 



202 A TEXT-BOOK OF GYNECOLOGY 

it is difficult for it to occur when we keep in mind the appearance of 
the chancroid lesion, which is the most reliable diagnostic by itself. 
Indeed, the punched-out, round, irregular, or ragged, often undermined 
ulcer, which rapidly spreads, accompanied with abundant secretion, and 
exhibiting an unhealthy, diphtheroid, worm-eaten surface, can not 
admit of confusion. At any rate, especially in the beginning, when 
no other diagnostic characteristics are present, in case of doubt it is 
better to suspend diagnosis, being sure that, on the following day, the 
doubt will be dispelled. 

Treatment. — As already stated, the use of douches with warm water, 
having in solution some borate of sodium or any other mild antiseptic, 
is advised. The general health of the patient must receive its proper 
care, and the use of mild saline purgatives is advisable when an- 
noyed with constipation, alkaline mineral waters when troubled with 
catarrhal conditions of the digestive organs, iron tonics and recon- 
structives when symptoms of anaemia and general denutrition are pres- 
ent. Locally, the application of a wash containing lead and opium is 
very useful, especially when the herpetic eruption is accompanied with 
pain and irritation. Touching the ulcerated surface with a solution 
of nitrate of silver, from 6 to 8 per cent, has given very satisfac- 
tory results. The surface is then covered with an innocent salve, as 
Wilson's ointment, or with vaseline containing some carbolic or sali- 
cylic acid. The application of powders is also used with some benefit. 
Iodoform is objectionable because of its odour; but aristol and euro- 
phen are applied with advantage on the exulcerated surface. The pow- 
ders have the disadvantage that they form crusts with the secretion, 
which soil the exulcerated surface. Eavogli prefers the use of powders 
when the surface is healing, at which time the parts may be dusted 
with oxide of zinc, subnitrate of bismuth, rice powder, or any other 
substance capable of keeping the surfaces' dry and separated. 

The application of camphorated alcohol has been used as an abor- 
tive measure, and in the same way Depas, of Lille, advocates the applica- 
tion of compresses of absolute alcohol, to which 2 per cent of resorcin 
and 1 per cent each of menthol and carbolic acid are added. 

Pruritus Vulvae. — In this affection there is no apparent eruption on 
the genitals; it is characterized only by an intense itching sensation 
of the vulva and of the vagina without apparent external causes. In 
cases of the presence of eczema, of lichen, prurigo, or of insects, the 
itching is due alike to the alteration of the skin and to the irritation 
of the insects; but in cases of pruritus vulvae the itching is the 
only symptom — one so persistent and so intense that it compels the 
woman to scratch and to rub the genitals, producing excoriations. If 
this condition lasts some time, then eczema, inflammation, swelling, 
and oedema of the skin of the genitals are often found, caused by the 
scratching and tearing of the skin. The continuous itching and the 
desire to scratch and rub the genitals makes the woman inclined to 
masturbation or to coitus, rendering her hysterical and nymphomani- 



DISEASES OF THE SKIN OP THE FEMALE GENITALS 203 

acal. The irritation from scratching and the inflammatory process of 
the external genitals spread to the mucous membrane of the vagina 
and cause a catarrhal discharge from this organ, which increases the 
itching sensation. 

Pruritus vulva? is more often met with at the time of the menopause 
in women who are of nervous disposition or suffering from the recog- 
nised neuroses. At other times it is a premonitory symptom of a great 
many lesions of these organs, as fibroma, and sometimes of carcinoma. 

The pathology of pruritus vulvse has been carefully studied by J. C. 
Webster. (Transactions of the Edinburgh Obstetrical Society, 1890-'91.) 

As regards the naked-eye appearances, there may be more or less 
hypertrophy, or none at all. As regards the hypertrophy in such cases, 
it is impossible to say whether it is to be associated with the primary 
pruritus or to be regarded as resulting from continued rubbing and 
scratching. It is not a constant factor. There are also many cases of 
simple hypertrophy without any accompanying itchiness. The micro- 
scopical changes found in the tissues removed in Webster's cases were 
of great interest, and were probably the cause of the disease. These 
changes were of the nature of a slowly progressing fibrosis, affecting 
chiefly the nerves and nerve endings of the clitoris and labia minora. 
Many of the nerves, if traced from deeper parts toward their termi- 
nations, were seen to acquire a dense fibrous character, some appear- 
ing as well-marked fibrous cords, the nerve fibres being compressed or 
destroyed. In some cases they could be followed to their special end 
corpuscles, which also showed the same changes. The changes were 
most marked in the clitoris. 

The Pacinian corpuscles did not appear to be affected, save in one 
instance where there were an abnormal number of cells in the central 
core. Some globular end bulbs showed an increased number of cells; 
others appeared as dense fibrous knobs. Some of the genital corpuscles 
showed the change in a marked degree, the windings of the terminal 
nerve fibres being often almost obliterated. The changes found in the 
connective-tissue framework of the clitoris and nymphse were different, 
being of a subacute inflammatory nature, and evidently more recent in 
origin than those found in the nervous structures. They were found 
most marked in the corium under the papillae, and affected especially 
the prepuce and nymph se, being found in the clitoris only in the glans 
under the epithelium, and much less marked than in the labia minora. 
In the corium of the latter were seen many minute vessels with abun- 
dant exudation of leucocytes into the perivascular lymphatics, while in 
many parts the subepithelial tissue was a mass of leucocytes and prolif- 
erating connective-tissue corpuscles. These changes were most marked 
in the hypertrophic nymphge. They were distinct from the chronic 
fibrosis affecting the nervous structures, and were, no doubt, due to 
the long-continued irritation of the scratching. They affected chiefly 
the superficial parts — viz., the prepuce and nymphae — the nerve fibrosis 
being most marked in the clitoris, in which there were only a very few 



204 A TEXT-BOOK OF GYNECOLOGY 

acute or subacute changes under the epithelium covering the surface 
of the glans. 

The causation of pruritus vulvae has always been shrouded in more 
or less mystery. While it is true that it is only a symptom, its pres- 
ence does not imply the existence as a cause of any of the recognised 
pruriginous diseases of the skin of the vulva. It is true that in these 
affections itching is a conspicuous and aggravating symptom, but it 
is one the existence of which is explained by manifest pathologic 
changes. In pruritus vulvae there are no such obvious changes; or, if 
there are, they are as liable to be consequences as causes. Bronson 
considers a general neurotic condition, either congenital or acquired, 
as a predisposing cause, and recognises a state of impaired conduction 
in the nerve of tactile sense as another causative factor. Though this 
usually occurs as a concomitant of hyperesthesia of the skin, it is pos- 
sible that it may exist independently of the latter, particularly in the 
atrophic changes of old age, while among the exciting causes he speaks 
of irritations transmitted from nerve centres, direct or local irritations, 
from irritants applied to the skin, or from intracutaneous sources, such 
as the lesions of trophic cutaneous diseases and their products; toxic 
or noxious materials deposited from the blood; effects of local nutritive 
disturbance or deranged metabolism in the cutaneous sensory nerves; 
and, finally, spastic contraction of the arrectores pilorum muscles. 
While this summarization of the etiology of the disease deals largely 
with more or less speculative pathology, it is still suggestive of what 
closer observation may prove to be the real causation of the disease. 
Ravogli, in common with other observers, recognises diabetes, or rather 
diabetic urine, as an exciting cause. Feinberg (Centralblatt fur Gynd- 
kohgie) described two cases of idiopathic pruritus vulvae, occurring 
during the course of pregnancy, in which the aggravating symptoms 
subsided after parturition. 

Treatment consists in cold applications, alcoholic or ethereal, in the 
form of compresses applied on the genitals. Cold is more apt to relieve 
the itching than warm applications. In these solutions some carbolic 
or salicylic acid may be dissolved in the ratio of 2 per cent, and in 
these cases affords some benefit. Sitz baths with warm water, to which 
some bran has been added or some sodium bicarbonate, are to be rec- 
ommended. In the same way the application of vaginal douches with 
mild solution of borate of sodium, alum, etc., are beneficial; these 
douches should be followed by the application of tampons dipped in 
some ointment containing opium; but the application which in Eavog- 
li's hands has been most frequently successful is a tampon dipped in 
ichthyol (25 to 50 per cent) and glycerine. In very severe cases resort 
to suppositories of cacao butter with one fifth of a grain of morphine or 
cocaine has been recommended. 

Kholmogoroff reports success from the use of galvanism with the 
positive electrode, insulated to its distal tip, introduced 4 or 5 centi- 
metres within the vagina, while the negative, covered with chamois 



DISEASES OP THE SKIN OF THE FEMALE GENITALS 205 

and moistened with a salt solution, was applied over the affected area. 
It should be remembered in this connection that chamois repeatedly 
applied to the skin may become infected and itself become the carrier 
of infection. Heidenhain applies compresses wet with a hot solution 
of a tablespoonful of tannin in a quart of water, the yagina having 
been previously douched with an antiseptic solution. This treatment 
is repeated every night. Mtrate of silver, sulphate of zinc in solution, 
and thymol in a 10-per-cent ointment, are recommended as valuable 
remedies. It is probable that for the relief of the purely functional 
pruritus careful attention to a hygienic regime comprises the best rem- 
edy. This should consist in frequent local ablution not attended with 
undue friction, in following a wholesome and laxative diet, and in 
relieving the generally accompanying constipation. 

Surgical Treatment. — When, however, pruritus vulvae ceases to be a 
purely functional disturbance and depends for its continuance upon 
the development of fibrosis in the terminal nerve filaments, as described 
by Webster, the change must be looked upon as permanent and topical, 
and constitutional remedies must be recognised as quite inefficient. 
Belief under these circumstances can be given the agonized patient 
only by freely excising the affected area. In determining the extent of 
this operation it is essential first to ascertain the limits of the pruri- 
ginous areas. These, when ascertained and delimited, should be freely 
excised. The operation will generally involve the removal of the 
clitoris and its prepuce, the labia minora, and frequently the integu- 
ment from the inner aspect of the labia majora. In the performance 
of this operation the procedure designated in the chapter on clitoridec- 
tomy may be followed, the only change consisting in the extension of 
the area of denudation. 

Parasitic Affections of the Skin of the Female Genitals. — The skin 
of this region is sometimes affected with the vegetable parasite Tricho- 
phyton tonsurans in the form of eczema marginatum. On account of the 
condition of the skin, which is often macerated by the perspiration, the 
affection has so peculiar an appearance that for a long time it has been 
discussed whether it was the result of the same parasite, and for this 
reason Hebra called it eczema marginatum. At present it is accepted 
that this affection is nothing else than an ordinary ringworm, modified 
in its appearance by the locality. The moist condition of the epi- 
dermis allows the parasite to grow with more vigour, and the increased 
inflammation gives the different appearance to the affection. It is an 
affection found, not only on the genitals, but wherever two surfaces 
of the skin are close to each other. In this way we find eczema mar- 
ginatum of the axilla, of the breast, and of the cruro-genital fold. 

It is usually seen when fully developed. It appears as a reddish, 
moist, pigmented area circumscribed by a red, somewhat raised border, 
forming a circle or an arc of a circle. The border is formed by small 
papules or vesicles covered with brownish-yellow crusts. The surface 
is often excoriated as a consequence of scratching on account of the 



206 A TEXT-BOOK OF GYNECOLOGY 

itching sensation accompanying this affection. The rings do not re- 
main limited to the genital sphere; sometimes when the disease is left 
without treatment they grow to reach the anal region, and spread on 
the pubis. 

It is rather difficult to demonstrate the presence of the Trichophyton 
tonsurans in the scales or in the crust, but with some patience and 
repeated experiments the fungus is found, in appearance like that of 
the ordinary ringworm. 

It is easily cured; sulphur is the best remedy. Eavogli directs the 
patient to wash the parts with green soap, and after washing and dry- 
ing, the affected skin is covered with a thick layer of Wilkinson's oint- 
ment, of which we have already given the formula (page 19-1). Bulkley 
recommends the use of sulphurous acid, applied in the form of com- 
presses on the surface. Many other remedies are used in trichophyton, 
such as chrysarobin or beta-naphthol, in the form of salves, which can 
also be applied with good results. 

The affection is easily manageable, and after six or eight applica- 
tions of Wilkinson's ointment, continued until the epidermis exfoliates, 
we are sure of the success of our treatment. 

Pediculi Pubis. — A kind of pediculus called Phtheirius inguinalis 
may be found infesting the hairy parts of the woman's pubic region. 
Although the hairs of the pubes are the ordinary habitat of this insect, 
yet it may also find its way to the hair of the axillae, and in the man to 
the beard. This insect has a peculiar shape, resembling the form of a 
crab, and for this reason it has been called crab louse, and vulgarly 
crabs. It hangs to the shaft of the hair, inserting its proboscis into 
the follicle so as to obtain its nourishment from the sebaceous glands. 
To the naked eye it looks like a yellowish scale or a little crust. It 
causes a great deal of itching sensation, but this is seldom so severe as 
to cause deep excoriation, as in the case of the body louse. It always 
comes by contagion; sexual intercourse is the most common way of 
transmission of this insect, but it can be taken also from clothing, bed- 
ding, and from contact with the seat board of a public water-closet. 

This insect is very inactive; it hangs fast to the hair and to the 
skin, so that it is difficult to detach it. With its powerful claws it holds 
firmly to the hair, so that in attempting to remove it, it slides for some 
distance before loosening its hold. The eggs of this louse are small 
and adhere to the hair. 

A close inspection of the part affected will reveal the presence of 
the insect and of the nits. 

Treatment. — The old application of mercurial ointment is still to 
be recommended; one or two applications are sufficient to destroy the 
insect and the nits. This application, however, is somewhat dirty and 
may produce irritation and dermatitis. The ointment of white precipi- 
tate is also recommended. In his clinic Eavogli finds that coal oil 
gives good results; two applications are enough to kill the insects and 
nits. Oleate of mercury has also a good effect. After any one of these 



DISEASES OF THE SK1X OF THE FEMALE GENITALS 207 

applications the patient takes a bath and changes the clothes in order 
to prevent a new transmission. 

Atrophy of the External Female Genitals (Kraurosis Vulvae). — 
Under the name of kraurosis vulvce there has been recently described an 
atrophy of the vulva. The name was given to the affection by Breisky, 
using the Greek name Kpavpos, parched, hence withered. The atrophy is 
strictly limited to the skin and to the subcutaneous tissue, involving the 
labia majora, the fourchette, and sometimes the perineum. Charles 
A. L. Eeed (Xew York Medical Journal, September 29, 1894) stated 
that he had never been able to observe either clinically or micro- 
scopically the extension of this disease to the mucous membrane of the 
ostium vaginae, and he believes that this affection is essentially re- 
stricted to the vulvar integument. For this reason the disease has also 
been given the more appropriate name of progressive cutaneous atrophy 
of the vulva. 

The first description of this disease is due to Eobert F. ^Veir, of 
Xew York, who in 1ST 5 described this affection as an ichthyosis vulvae. 
(Ichthyosis of the Tongue and Vulva, New York Medical Journal, 
March, 1875.) Although he believed that he was describing a case of 
ichthyosis, yet the symptoms have such an analogy with those of this 
affection that there is no doubt that he described a case of kraurosis. 
The knowledge of this disease is reallv due to Breiskv, of Prague 
(Archiv fur Heilkunde. Prague, 1885). In 1885 he reported twelve cases 
with a careful study of the symptomatology and of the pathologic 
alterations. Possibly such cases had come to the attention of the 
gynecologist before that time, but the condition had not been pointed 
out as a pathologic entity. Since the publication of Breiskv the sub- 
ject has been brought to the attention of the Obstetrical and Gyneco- 
logical Society of Berlin, where, after a full consideration, the disease in 
question was recognised as a morbid entity. 

The first changes perceptible to the naked ei/e are small reddish 
areas around the ostium vaginae; they are not elevated; on the contrary, 
they are somewhat depressed. They are painful to the touch, and sex- 
ual intercourse is painful and futile. The vaginal orifice is very nar- 
row, and there is a diminished elasticity of the tissues. The skin and 
the mucous membrane have at this point lost a great deal of their 
pigment and have become thin and translucent, tense and glossy, so as 
to have lost all the normal folds of the vulva. The ostium vaginae is 
very narrow. The shrinkage is one of the leading features of this 
disease, but it is manifested, not over the whole region, but in different 
areas. From these centres the process gradually extends until the 
vulva has been entirely involved. The labia minora are fused together 
with the labia majora, and scarcely a trace of them is to be seen (Fig. 
72). In some cases the mons veneris is also found in an atrophic con- 
dition, associated with complete alopecia. 

According to the observations of Breisky, in none of his cases had 
there existed symptoms of inflammation or of exanthematous affection 



208 



A TEXT-BOOK OF GYNECOLOGY 



in the external genitals, 
sensation was present. 



In some of his patients an unbearable itching 
Some of the women were pregnant and the 



itching sensation spontaneously disappeared at 
tion. In one of the gynecological cases the 



the 




j most 

night; 

leucor- 

menor- 



end of the gesta- 
woman suffered with 
an itching sensation, 
which lasted only a 
few weeks. In two 
private cases he 
found one patient 
who had been afflict- 
ed with pruritus for 
several years, the af- 
fection bein^ 
annoying at 
she also had 
rhcea and 
rhagia. In another 
case the pruritus had 
been present for 
nearly three years, 
with relapses at the 
time of the menstru- 
ation lasting from 
two to three days. 

Breisky drew his 
conclusions from the 
consideration of all 
his cases as follows: 
That chronic vaginal 
catarrh was present 
in 4 cases; that in 2 
cases scars were pres- 
ent from progressed 
scrofulous abscesses 
of the cervical 
glands; not one had 
suffered with syphi- 
lis; 1 was sterile, 
2 were multipara 1 , 5 had given birth to one or more children. Not 
one of the multiparae had had trouble with her delivery, and in no one 
had there been an inflammatory process of the external genitals. Al- 
though Breisky was of the opinion that this disease was the result of 
a chronic eczema, yet he never could find this affection in his cases. In 
the same way the pruritus seems to be one of the principal causes of 
this disease, and yet only in 3 of his cases was it present. 

Indeed, the etiology of this disease is very obscure. It occurs with- 
out previous existence of other diseases of the skin of the vulva. In 




t &HTOfo i 



Fig. 72 (Reed). — " The labia minora are fused together with 
the labia majora and scarcely a trace of them is to be 
seen." — Eavogli (page 207). 



DISEASES OF THE SKIN OF THE FEMALE GENITALS 



209 



the cases reported by Orthmann no sugar could be found in the urine 
and there was no history of syphilis. In the cases reported by Reed, in 
one there was a history of progressed syphilis in early life, but no later 
manifestations could be found. So that it has been established and 
confirmed by Lewin (C entralblatt fur Gynakologie, 189i) that the 
atrophy of the vulva is not of a syphilitic origin. Gonorrhoea and no 
specific chronic catarrh are considered by some observers as probable 
etiological factors. This disease is found only in women over forty, 
which would identify this atrophy with trophic changes induced by 
advancing age. Olshausen lays a great deal of stress on the extirpation 
of the uterine appendages as a cause of this atrophy, which relation was 
found in one of Reed's cases. In one of Jevonsky's cases the affection 
had started from a cicatrix in a lacerated perineum. From the multi- 
plicity of the possible causes held to be factors in this disease, it seems 
that no one must be considered as such, and Reed prefers the theory 
that the peripheral trophic nerves or their ganglia are to be consid- 
ered as the origin of this disease. 

This histologic condition of the skin, as found by H. W. Bettman 
in Reed's cases, shows, as one of the most important features, a marked 
hyperemia, which in some places assumes the character of true hemor- 
rhage. The epi- 
dermis shows 
great changes ac- 
cording to the 
different places ; 
in some points 
it is hardened, 
thickened, and 
hypertrophic, in 
other places thin 
and atrophic, and 
in other places 
has nearly disap- 
peared (Fig. 73). 
The corium shows 
two different con- 
ditions. One is 
due to the exuda- 
tion and infiltra- 
tion of round in- 
flammatory cells 
into the stroma of 
the corium, and 
the other is due to 

the sclerosis and atrophy of the tissues. These are two different condi- 
tions, one the consequence of the other, and due to the changes of the 
process. In the first condition the papillae are infiltrated, in the second 
15 




Fig. 73 (Reed). — " The epidermis shows great changes according 
to the different places." — Eavogli. 



210 A TEXT-BOOK OF GYNECOLOGY 

they are shrunken and have nearly disappeared. In the same case the 
different sections show a difference in the pathologic alterations. From 
the above observations it is plain that the anatomic lesions are of a 
different character, according to the stage of the disease. In the begin- 
ning the hyperemia and exudation predominate in the tissues, later the 
lesions consist of a thickening and shrinking of the tissues in sclerosis. 

The subjective symptoms of this disease consist at first of painful 
points and a painful inelasticity, which are impediments to the copula- 
tive act. In the later period there is a loss of sensation in the entire 
diseased area. Itching is not a constant symptom, and in most of the 
cases is absent. In 35 cases referred to by Ohmann-Dumesnil 13 cases 
were troubled with itching in various degrees. In 5 cases referred to by 
Orthmann (Z eitschrift fur Geburtshillfe und Gynakologie, Stuttgart, 
1890) only 1 patient complained of an itching sensation. In 6 cases re- 
ferred to by Eeed, 2 only were annoyed in that way, and that only at 
the beginning of the affection. 

The diagnosis is often made as vaginismus in the beginning of the 
affection, but careful inspection will reveal the sensitive areas at the 
ostium vaginas and the already begun shrinkage of the vulvar integu- 
ment. When the areas of atrophy have begun it is possible to mistake 
the disease for ichthyosis, but in this disease there are adherent scales, 
which are never found in kraurosis. 

In reference to the prognosis, Tait says that the patient should 
always be informed that the progress of the disease will extend over 
years, that it will certainly get well in time, but that treatment from 
time to time will give relief. It seems that the recovery alluded to is 
nothing else than the disappearance of the subjective symptoms. We 
can not promise recovery to the patient affected with this disease under 
any circumstances. 

The treatment may be divided into palliative and curative. The 
first is obtained by remedies to relieve pain. Carbolic acid in the form 
of a lotion, on account of its anaesthetic quality, affords some temporary 
relief. Tait recommends the application between the small labia, at 
bedtime, of a piece of cotton dipped in a solution of neutral acetate of 
lead in glycerine, as capable of giving relief. A mixture of tannin and 
salicylic acid in glycerine has been used in the same way with good 
results. Tait condemns cocaine as useless and irritating. The appli- 
cation of nitrate of silver in stick to cauterize the degenerated patches, 
so as to obtain a good cicatricial tissue, diminishes the sufferings, but 
does not arrest the progress of the disease. Heitzmann tried to scrape 
off with a sharp curette the hard tissues involved, but the length of time 
this process takes, and the poor results it gives do not commend it. 
The general tonic treatment must be strongly enforced so as to improve 
the general condition of the patient. 

As a curative treatment Reed mentions an operative process by 
excision. This he applied in an incipient case of kraurosis, which was 
limited to a vascular ring around the ostium vaginae. The mucous 



DISEASES OF THE SKIN OF THE FEMALE GENITALS 



211 



membrane of this locality was completely excised in the form of an 
ellipse, and the denuded edges were brought together by means of in- 
terrupted sutures. The patient had some temporary relief, but seven 
months after, the disease appeared on the integument. Martin, as re- 
ported by Orthmann, has begun the method of a complete excision, 
which must be applied according to the affected parts, removing the 
tissue thoroughly and approximating the edges. In this way eight cases 
operated upon by Martin 
completely recovered. The 
same operation in the hands 
of Reed has given very good 
results (Fig. 74). It is neces- 
sary not to operate in the be- 
ginning of the affection, be- 
cause the process is not yet 
limited, and it is liable to 
spread, in spite of the opera- 
tion. But when the operation 
is performed at the time that 
the sclerotic process is lim- 
ited, then there is no danger 
of a recurrence of the disease. 
Vulvar Adhesions. — The 
vulva externally consists of 
integument arranged in a 
series of folds with proximal 
surfaces. The fold between 
the labia majora and the 
labia minora and that be- 
tween the glans of the cli- 
toris and its prepuce, are 
striking examples, while the 
surfaces of the labia majora 
lie in approximation, particu- 
larly in case of pudendal re- 
dundancy. These proximal 
surfaces are ordinarily pre- 
vented from becoming ad- 
herent through the protective influence of the epithelial layer of the 
skin. There occur cases, however, of antenatal blending of these 
structures (see Malformations of the Vulva); others in which adhe- 
sion occurs speedily after birth; and still others in which, as the 
result of desquamative or similarly destructive inflammation of the 
skin, the epithelium becomes destroyed and the now denuded and ap- 
proximated surfaces unite. Morris (Transactions of the American Asso- 
ciation of Obstetricians and Gynecologists, 1892) called attention to 
the frequent adhesion of the prepuce to the glans clitoridis, a condition 




Fig. 74. — " The same operation in the hands of 
Reed has given very good results." — Eavogli. 



212 A TEXT-BOOK OF GYNECOLOGY 

which, he insists, exists, to a greater or less extent, in 80 per cent 
of Aryan American women. He finds it very rare among the negresses; 
and looks upon its occurrence as a phase of evolutional change. When 
preputial adhesions are extensive, the glans clitoridis and the impris- 
oned mucous follicles remain comparatively undeveloped, but attain 
their normal growth after liberation of the adhesions. When these 
adhesions are slight they are of practically no clinical importance, but 
when they embrace a considerable part, or the whole, of the glans cli- 
toridis, they cause profound disturbances; so much so, that Morris con- 
siders that preputial adhesions probably form the most common single 
factor in invalidism in young women. Bacon (^American Gynecological 
and Obstetrical Journal) summarizes his observations and experience of 
preputial adhesions in the female, with the statement that they are 
prone, by the irritation they induce, to cause masturbation and the 
various neuroses; and that the prevention by them of the development 
of the glans clitoridis frequently results in eroticism. The damaging 
influence of these adhesions is experienced relatively more in the child 
than in the adult, for the reason that in the former the reflex nervous 
centres are less under the control of inhibitory impulses, and peripheral 
irritation consequently produces disturbances that would not be ex- 
perienced in maturer years. The treatment of this condition consists in 
breaking up the adhesions as soon as they are found, or particularly as 
soon as they are recognised as causes of mischief. Bacon is of the opin- 
ion that every female child should be examined, and the clitoris, if 
found adherent, should be liberated in the earlier weeks of life. The 
operation for this purpose consists in peeling the prepuce off the glans 
by means of a grooved director or other blunt instrument, and in keep- 
ing the area dressed antiseptically until it heals, care being taken fre- 
quently to separate the proximal surfaces to prevent readhesion. In 
labial adhesions, particularly when these are of antenatal occurrence, 
the structures are frequently so intimately fused as to defy separation. 
In certain of these cases the labia minora will be found implanted upon 
the surfaces of the labia majora so intimately that upon retracting 
the latter the former can be detected only in outline. This condition is 
rarely of any. clinical importance. It may, however, give rise to local 
disturbance from the accumulation of sebaceous matter secreted by the 
rudimentary follicles that are incarcerated within the adhesions. When 
this occurs the accumulation should be liberated by incision, while at 
the same time an effort should be made to break up the fusion. 



CHAPTER XVni 

HYPERTROPHIC AND HYPERPLASTIC DISEASES OF THE 
PUDENDAL ORGANS 

Hypertrophy of the clitoris — Condylomata — Elephantiasis — Polypi — Treatment. 

The hypertrophic and hyperplastic diseases of the pudendal organs 
are, as a rule, acquired. Congenital hypertrophy of the vulva is com- 
paratively rare and is confined to single parts of the pudendum. The 
parts usually found enlarged in congenital hypertrophy are the labia 
minora and the clitoris. In the case of the former, it is often difficult to 
decide at the time when the observation is made whether one is deal- 
ing with a true congenital condition or with one acquired by accidental 
pathologic processes. Manipulations are employed by certain tribes 
to bring about a hypertrophy of the labia minora. As is well known, 
the South African Hottentots, by certain methods practised on their 
female children, produce that enormous hypertrophy of the labia 
minora described as the "Hottentot apron." 

Hypertrophy of the clitoris, while occasionally an acquired condi- 
tion, is probably the most common form of congenital hypertrophy of 
the pudendum. A large number of cases of this kind have been de- 
scribed, one of the most remarkable by Fehling, who reported the case 
of a girl of twenty-one years with a clitoris five inches long, as thick as 
a thumb, and with a glans one inch long. Extensive congenital hyper- 
trophy of the clitoris is frequently combined with atresia of the labia 
minora, descent of the ovaries, and other anomalies obscuring the true 
sex of the individual, and bringing about the condition known as female 
pseado-liermaplirodism. (See Malformations of the Vulva.) This con- 
dition is simply one in which, owing to anomalous development, the 
pudenda simulate to a certain degree the male organs of generation. 

Of the acquired hypertrophies and hyperplasias, there are two im- 
portant groups of morbid conditions which have to be considered, 
viz., the condylomata and elephantiasis. Both of these are more prop- 
erly to be looked upon, not as truly neoplastic formations, but as hyper- 
trophic and hyperplastic diseases, since they develop upon an inflam- 
matory basis. 

Condylomata are usually present as elevated condylomata (C. acu- 
minata), more rarely as broad condylomata (C. lata). They develop 
on an inflammatory basis, which may be simple, gonorrhceic, or syphi- 
litic. Condylomata, are, however, not to be considered as a specific 

213 



214 A TEXT-BOOK OF GYNECOLOGY 

process, but as a secondary hypertroplry, developing, as the case may 
be, on either a specific or a nonspecific soil. In an early stage these 
hypertrophies form small, pointed elevations, warty in character. They 
are found on the labia majora and labia minora, the clitoris, the mons 
veneris, and they spread not infrequently over the skin of the peri- 
neum, around the anus, and over the inner surfaces of the thighs. 
They are first found united in smaller groups, with spaces between 
them free from excrescences. Later on, they often become confluent, 
forming large masses which hide entirely from view the whole of the 
pudendum, the latter being then covered by an uneven, irregular, 
ragged, papillomatous, or cauliflower mass (Fig. 75). In colour they 




i 




WTHiPM 



Fig. 75. — " They become confluent, forming large masses which hide from view the whole 
of the pudendum." — Herzog. 

may vary from a grayish-white to a pink or rose-red. The surface may 
be dry and shiny, or it may be moist. It is usually not ulcerated, unless 
it has been subjected, in consequence of very improper care, to a good 
deal of friction or other irritation. One of the notable features of these 
condylomatous masses is their very rapid growth during the period of 
gestation. This is evidently due to the increase of the blood supply to 
the genital organs in pregnancy. 

Microscopic examination of condylomatous masses shows that they 
consist mainly of enormous hypertrophies of the papillary layer of the 
skin. The papilla?, normally short and simple, become elongated and 
branched like a tree; they divide dichotomously or in a digitate manner. 
These hypertrophied papilla? consist of connective-tissue fibres and 
round, oval, or stellate cells, supporting a network of blood vessels. The 



HYPERTROPHIC AXD HYPERPLASTIC DISEASES 215 

finest papillary branches are mainly composed of blood vessels with 
only scanty connective-tissue fibres and cells as a stroma. The hyper- 
trophic fibrillar connective tissue frequently shows an extensive round- 
cell infiltration consisting of polynuclear leucocytes and mononuclear 
lymphocytes. The epithelial layer covering these complicated hyper- 
trophic papilla? is thickened. The thickening is noticeable in the Mal- 
pighian layer, or stratum germinativum, as well as in the older more 
superficial strata. 

Condylomatous, cauliflower masses of the vulva, may be confounded 
with carcinomata of the vulva, which are also apt to form cauliflower 
excrescences. Besides the clinical features which have to be consid- 
ered, a careful microscopic examination of a series of sections, made 
vertically in the direction of the papillary layer, can always clear up the 
diagnosis. We have in carcinoma as the most prominent histological 
feature the great proliferation of the epithelia of the skin. These pro- 
liferating cells form alveolar or tubular nests which are surrounded by 
connective tissue. In condylomata, on the other hand, we have the 
great hypertrophy of the connective tissue, and the hypertrophic con- 
nective-tissue masses are surrounded by layers of epithelial cells. 

There occur also certain small excrescences on the pudendum, due 
to frequent masturbatory manipulations, which must not be mistaken 
for what is to be classified as a true condyloma of the vulva. The 
excrescences of this type, which may to some extent simulate an early 
stage of condylomata acuminata, are generally found on the mucous 
membrane between the margin of the hymen and the labia minora, and 
-also in the neighbourhood of the external meatus of the urethra. They 
are easily distinguished from true condylomata by the fact that they 
are small in size, simple, and not branched. They occur on the mucous 
surfaces only, and do not spread to the epidermal surfaces of the vulva 
or neighbouring parts. They are never infectious in nature, and occur 
most frequently in virgins of a hysterical disposition. Keeping these 
points in view, one is not likely to mistake these masturbatory excres- 
cences for true condylomata. 

The treatment of the venereal warts consists in their removal. This 
is done either by surgical means or by caustics; the first, however, is 
always preferable to the second. 

In case of small warts on the female genitals, they must first be 
washed with a solution of bichloride (1 to 1,000), or with a solution of 
carbolic acid (1 to 100). After drying them with cotton they are soaked 
with a cocaine solution (5 per cent), and then they are scraped off 
with a sharp curette, removing the small growths completely. On ac- 
count of the richness in blood vessels of the warts at their points of in- 
sertion they bleed freely. The bleeding is stopped by the application of 
a tampon dipped in a saturated solution of perchloride of iron. AVith 
this process Eavogli has obtained very good results, and he states that 
very seldom has he seen a recurrence. In case the warts should grow up 
again, it is better to destroy them at once by touching them with a 



216 A TEXT-BOOK OF GYNECOLOGY 

solution of chloracetic acid, lactic acid, or acid nitrate of mercury. Tay- 
lor recommends the use of collodion containing bichloride of mercury, 
30 grains to the ounce, or salicylic acid, 1 drachm to the ounce. 

Caustics are used independently of the curetting to obtain the 
destruction of the venereal warts. A strong solution of chromic acid, 
from 1 to 4 drachms to the ounce of water, has been applied, but 
the pain which results is absolutely unbearable, and the cauteriza- 
tion is not limited, affecting also the healthy skin. J. W. White re- 
ferred to the case of a woman who died in collapse in twenty-seven 
hours from the application of this solution on warts affecting the vulva 
and the anus. (Journal of Cutaneous and Genito-urinary Diseases, 
1889.) 

When the condylomata have attained an extraordinary develop- 
ment, it is necessary to remove them with the galvano-cautery loop, 
by which means we can prevent loss of blood. 

Wlien there are warts round the meatus of the urethra, care must 
be taken not to cause any laceration or wound, which may be the origin 
of a scar structuring the meatus. 

Taylor recommends the application of a powder of equal parts of 
calomel and salicylic acid, which has often given him very satisfactory 
results. 

Caesar Boeck (Monatsliefte fur praktisclie Dermatologie, 1886) rec- 
ommends the application of a watery solution of resorcin on the con- 
dylomata, especially when they have a tendency to recurrence. He uses 
also a powder of resorcin, eight parts, and bismuth subnitrate and boric 
acid, one part each, to dust the condylomata, claiming prompt and 
effective results. 

The following formula, which is applied after the warts have been 
well bathed with a solution of bichloride, as above described, has been 
also praised: 

3J Acidi salicylici, ) __ x 

y-^-i -. . . y aa oss. : 

Cnrysarobmi, j 

Collodii flexilis §j. 

M. To be applied twice a day. 

In Ravogli's clinic he has found formaldehyde very useful, which 
he applies in a strength of from 8 per cent to 42 per cent, as it 
comes in commerce. The application of pure formaldehyde is rather 
painful and requires the previous use of cocaine to diminish the pain. 
One or two applications have been sufficient to cause the condyloma to 
become necrotic and slough off. It is necessary to direct attention to 
the condition of the vagina and of the womb, to be sure that gonorrhoea 
has entirely ceased. 

Elephantiasis vulvae may be defined as a pale whitish tumour for- 
mation, or swelling, arising from the labia majora and labia minora and 
from the clitoris. It is by no means an easy matter to properly classify 
elephantiasis vulvae. There is practically nothing known as to the true 



HYPERTROPHIC AND HYPERPLASTIC DISEASES 



217 



etiology of this affection, but it appears that most cases of elephanti- 
asis develop on an inflammatory soil. It is certain that all fully devel- 
oped and characteristic cases histologically represent an immense hyper- 
trophy of connective-tissue elements. Hence elephantiasis vulvae is here 
classified under hypertrophic diseases of the pudendal organs. It must, 
however, not be forgotten that elephantiasic formations in other parts of 
the skin have been shown to be true neoplasms, lymphangeiomata — i. e., 
tumours consisting of newly formed lymph vessels and other lymphatic 
elements. 

Elephantiasis vulvse may develop from a single place, or it may be 
multiple from the start, the single component parts becoming confluent 
later on in the course of the disease. The connective-tissue prolifera- 
tion in elephantiasis leads to the largest tumour formations that are 
found in connection with the pudendal organs. In its incipient stages, 
elephantiasis can not be distinguished clinically and macroscopically 
from any simple noninflammatory hypertrophy, but, later on, the enor- 
mous size of the hypertrophic for- 
mation distinguishes it clearly 
from any other known condition. 
In growing, the tumour gets so 
heavy and large that it becomes 
pedunculated in consequence of 
its own weight, the main mass 
often reaching down to the knees. 
While, with us, elephantiasis 
vulvae is a comparatively rare dis- 
ease, it is quite frequently met 
with in some of the Eastern and 
tropical countries. The different 
forms of this affection have been 
variously classified according to 
certain prominent morphological 
characters. Tumours showing 
even surfaces have been called ele- 
phantiasis fibrosa, while those 
showing a warty surface have been 
called papillary elephantiasis (Fig. 
76). Another classification makes 
three subdivisions, as follows: 
Smooth surfaced tumours cov- 
ered by skin which is not mate- 
rially different from the surrounding epidermis — elephantiasis glabra; 
tumours showing an irregularly nodular surface — elephantiasis tuberosa; 
and tumours with a surface showing numerous small warts and excres- 
cences — elephantiasis condylomatosa. 

The microscopic picture of elephantiasis vulvae varies according to 
the variety of the tumour and its stage of development. In the smooth 




Fig. 76.—" Tumours showing a warty surface 
have been called papillary elephantiasis P 
— Herzog. 



218 



A TEXT-BOOK OF GYNECOLOGY 



and tuberous forms the great mass of the tumour consists of a tissue 
composed of old fibres quite poor in nuclei. This connective tissue 
shows a marked cedematous infiltration and is sparingly vascularized. 
Capillaries and small arteries exhibit a perivascular round-cell infiltra- 
tion. The papillary body of the derma is poorly developed, the epi- 
thelial layers are thinned out, sebaceous and sweat glands are present 
in small numbers only, and even absent over large territories. While 
in the first two forms described, the papillary body is not hypertrophic, 
but rather atrophic, the third form, the elephantiasis condylomatosa, is 
characterized, like the true condylomata, by a well-marked hypertrophy 
of the papillae of the skin. In all three forms, when well advanced, 
there is also a great deal of thickening of the subcutaneous connective 
tissue, in which sometimes evidences of new formation of lymph vessels 

may be found. Pozzi 
and other French au- 
thors describe the his- 
tory of elephantiasis 
as presenting a num- 
ber of stages. The 
hypertrophied skin, 
according to their de- 
scription, first takes 
on an embryonal type, 
containing also large 
lymph spaces like 
those found in true 
lymphangeiomata. 
There occurs then, 
after an oedema has 
been established, an 
extensive lymph stasis 
and infiltration of the 
tissues with lymph. 
In this stage, there 
are also found in the 
elephantiasic tissues 
lymph glands in a 
state of fibrous de- 
generation. The last 

Fig. 77.—" The prepuce, now divided into two flaps, is cut stage is represented 

away."— Reed (page 220). Dv an enormous thick- 

ening of the skin, 
which, according to the French authors, from whom others differ, com- 
prises all the layers. According to the view now generally adopted, the 
thickening in most cases is chiefly confined to the subpapillary and sub- 
cutaneous layers. 

Superficial ulcerations not infrequently occur when the tumour 




HYPERTROPHIC AND HYPERPLASTIC DISEASES 



219 



has attained a larger size, and sometimes the lymph vessels are so 
greatly enlarged and dilated that they produce a lympliorrhcea from the 
ulcerating portions. 

The etiology of elephantiasis is still very obscure. Patients suffer- 
ing from elephantiasis vulvae not infrequently present the cicatrices of 
inguinal buboes or scars on the vulva. Frequently a history of syphilis 
may be obtained, and undoubted syphilitic manifestations may coexist 
with elephantiasis. The latter, however, can not be eradicated by an 
antisyphilitic treatment, though one sees occasionally a transitory im- 
provement after the free exhibition of the iodides. 

Polypi of the vulva, which authors frequently classify under neo- 
plasms of the pudendal organs, belong more properly, if one excludes the 
true fibromata, to the hypertrophic and hyperplastic diseases. These 
potyps, usually found in the neighbourhood of the external meatus, rep- 
resent hypertrophies of the mucous membrane of the vestibule. They 
vary from the size of a 
pea to that of a hazel- 



nut. 



are 



soft and 
pinkish in colour, 
smooth or mulberry- 
like, sessile or pe- 
dunculated. Micro- 
scopically, they show 
a loose fibrillar con- 
nective tissue with 
round - cell infiltra- 
tion, are covered by 
squamous epithelial 
cells, and often con- 
tain glandular spaces 
lined with columnar 
epithelium. They are 
due to inflammatory 
irritations, and it has 
recently been found 
that they sometimes 
contain gonococci. 

The treatment of 
hypertrophic and hy- 
perplastic diseases of 
the pudendal organs 




is almost 
surgical, 
should be 
the same 
source of 



Fig. 



-" The exposed raw surfaces are closed by a ser 
of fine catgut sutures."— Reed (page 220). 



exclusively 
Polypi 
treated in 

manner. Acquired enlargement of the clitoris, when a 
persistent local or constitutional disturbance, should be 



treated by extirpation. (See Clitoridectomy.) E. C. Dudley looks 



220 A TEXT-BOOK OF GYNECOLOGY 

upon acquired hypertrophy of the clitoris, and more particularly its 
prepuce, as being ordinarily the result of masturbation. Those cases 
in which the clitoris is moderately enlarged and surrounded by an 
abundance of loose, flabby, redundant preputial skin, he treats by what 
he calls circumcision. The prepuce is slit up on the dorsum of the cli- 
toris, as would be done in a similar operation on the male, or as is done 
in the initial step of clitoridectomy. The prepuce, now divided into 
two flaps, is cut away by seizing first one flap and then the other with 
a forceps and cutting it off at its base with the scissors (Fig. 77). The 
exposed raw surfaces are closed by a series of fine catgut sutures 
(Fig. 78). 



CHAPTEK XIX 

NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 

(A) Benign neoplasms of the pudendum : Varices, fibromyomata, pure myomata, 
myxomata, lipomata, enchondromata, neuromata, cysts — Benign neoplasms of 
the vagina: Cysts, fibromata — Treatment — (B) Malignant neoplasms of the 
pudendum: Carcinomata, sarcomata, melano-carcinomata — Malignant neo- 
plasms of the vagina : Sarcomata, carcinomata — Treatment : Excision — Clitori- 
dectomy — Extirpation of the vagina. 

Benign Neoplasms 

The pudendal organs, like other parts of the female genitalia, may 
become the seat of neoplastic diseases. These neoplasms, from a histo- 
pathological standpoint, are to be divided into connective-tissue tumours 
and epithelial new growths. For practical purposes it seems advisable 
here to separate the nonmalignant from the malignant new growths. 
Among the former there will be included in this consideration some 
pathologic conditions which, strictly speaking, do not belong to the 
tumours at all. 

Benign Neoplasms of the Pudendum. — It is a matter of doubt 
whether true henlangeiomata — i. e., tumours developing from and char- 
acterized by a new formation of blood vessels — have been observed in 
the pudendal organs. There are to be found, however, in literature very 
few reports according to which true neoplastic angeiomata have been 
observed in the vulva. 

The condition frequently found and described as varicose tumour of 
the vulva is not a genuine neoplasm, but represents varicosities due 
either to local or to general disturbances of circulation (Fig. 79). All 
circulatory disturbances of the lower half of the female body have a 
tendency to lead to marked manifestations in the vulva, its great sup- 
ply of blood vessels favouring very much venous stasis and the for- 
mation of varicosities. Pregnancy is a most fruitful cause of enlarged 
congested veins in the pudendal organs. We then find the veins of 
the labia majora greatly congested and dilated, and they rise as promi- 
nent purple swellings over the level of the surrounding skin. Large 
tumours of the ovaries, as well as fibromyomata of the uterus, may 
produce similar swellings. Valvular lesions of the heart, as well as 
nephritis, cause enormous oedema of the vulva and produce swellings 
of the labia majora that attain at times great dimensions. Chronic 

221 



222 



A TEXT-BOOK OF GYNECOLOGY 



inflammatory conditions in the pelvis also lead occasionally to vari- 
cosities of the pudendum. The greatly dilated and enlarged veins may 
undergo secondary changes, as phlebitis and fatty or calcareous de- 
generation, when there may occur, even in the absence of any appre- 
ciable force or insult, 
spontaneous hemor- 
rhage into the tis- 
sues ; a hematoma 
vulvas is thus estab- 
lished. (See Inju- 
ries of the Vulva.) 

Among the be- 
nign true tumours 
of the vulva the 
fibromata and fibro- 
myomata are prob- 
ably the most com- 
mon, though they 
are by no means fre- 
quently met with. 
These new growths 
take their origin 
from the subcuta- 
neous connective tis- 
sue of the labia ma- 
jora and labia mino- 
ra, more rarely from 
the clitoris. They 
form hard, somewhat 
nodular, roundish, 
oval, or elongated 
masses, covered by 
normal skin. Histo- 
logically these tumours consist of newly formed, wavy, fibrous, connect- 
ive tissue, very poor in nuclei, which is surrounded by a capsule made 
up of a condensed tissue of the same type. The skin is generally 
somewhat movable over the capsule and is not much changed in its 
structure and appearance. The tumour proper frequently contains, 
besides fibrous connective tissue, nonstriated involuntary muscle fibres 
or cells, so that the neoplasm assumes the character of a fibromyoma. 

Pure myomata of the vulva are very rare, though they have been 
observed occasionally. While the tumours of the fibromyomatous group 
are, as a rule, firm, hard, and solid, there may occur in them, in con- 
sequence of lymph stasis, lymphangeiectatic spaces of large extent. In 
a case of this kind, diagnosis between fibromyoma and elephantiasis 
may be impossible without the aid of a microscopic examination. The 
latter, however, will clear up the diagnosis. The fibromata show a 




Fig. 79. — "The condition frequently found and described as 
varicose tumours of the vulva." — Herzog (page 221). 



NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 223 

well-circumscribed proliferation and new formation of connective tis- 
sue, while in elephantiasis the hypertrophic processes of the connective 
tissue are diffuse and infiltrating, and there are also characteristic 
changes in the skin, which is practically unchanged in fibroma and 
fibromyoma. 

These tumours, as has been shown recently, frequently do not arise 
from the pudendal organs proper, but from the round ligament, and 
only later on in their growth and development descend into and en- 
croach upon the pudendum. Fibrous tumours starting primarily from 
the fascia of the pelvis may likewise in the course of their development 
and growth descend into the pudendum and present as tumours of the 
latter. 

The fibromata and fibromyomata of the pudendal organs have been 
observed at all ages from about the age of puberty until long after the 
climacteric period. They may be single or multiple. Their growth is 
usually slow, but they may become very large in size, reaching down 
to the knees, and weighing as much as fifteen pounds and more. When 
these fibrous tumours attain a large size they have a tendency to become 
pedunculated. Some fibromata show a pedunculated character from the 
start, forming small, elongated projections from the integument of the 
labia majora. They have been described as fibroma molluscum or mol- 
luscum pendulum of the vulva. 

The larger fibromata of long standing are apt to become ulcerated 
on the surface by pressure and lack of proper care and cleanliness. 
They are also liable to undergo calcareous degeneration. Another sec- 
ondary change to which they may become subjected, consists in an 
extensive oedematous infiltration, in consequence of which the fibres 
composing the neoplasm become pushed apart. Such tumours are not 
hard, but rather soft; they may even show pseudo-fluctuation, and 
microscopically their tissue looks very much like a myxoid degenera- 
tion, though it really only represents an extensive oedematous infiltra- 
tion. Fibromata so changed have frequently been reported as myxo- 
mata or myxofibromata. 

Lipomata of the vulva are rare. They are occasionally found in the 
mons veneris or in the labia majora and form well-differentiated round- 
ish tumours. They are very much softer than fibromata, and, like them, 
are sometimes pedunculated. Like the fibromata, the lipomata of the 
vulva, have a tendency to increase rapidly in size during pregnancy, to 
again somewhat decrease after the termination of gestation. A very 
few cases of congenital lipoma of the labium majus have been reported. 

Enchondromata and neuromata of the vulva have been described, but 
since these reports are not based upon a microscopic examination, they 
can not be accepted as valid evidence of the actual occurrence of such 
tumours. 

Cysts of the vulva may here receive some mention, although they 
are almost without exception not true neoplasms, but mere retention 
cysts. The cysts found most frequently in the region of the vulva are 



224 A TEXT-BOOK OF GYNECOLOGY 

developed from the glands of Bartholin, either from the gland proper 
or from its secretory duct. (See Vulvo-vaginal Gland.) 

Other cysts similar in character to those of the vulvo-vaginal gland 
take their origin from Gartner's duct, which, as is well known, occa- 
sionally extends downward into the vulva. 

There are also sometimes found in the labia majora atheromatous 
cysts and dermoids. They are lined internally by squamous and some- 
times by cylindrical epithelium; acinous glandular structures have been 
described in connection with such cysts. Small, yellowish, translucent 
cysts, observed not uncommonly on the hymen, are, as their structure 
and contents show, retention cysts of sebaceous glands. There have 
also been observed on the hymen small multiple cysts of the character 
of lymphangeiectatic formations. Aside from the cysts of the vulvo- 
vaginal glands due to gonorrheal infection, cysts of the pudendal 
organs, as before described, have no important practical bearing; they 
are generally discovered only accidentally, not giving rise to any symp- 
toms. In rare cases larger cysts of this type may give rise to slight in- 
conveniences in consequence of their size. 

Benign Neoplasms of the Vagina. — Cysts of the vagina are not so 
very uncommon. According to the statistics of Neugebauer, they are 
found in one of every six hundred women presenting themselves for 
examination. They are usually solitary, and when multiple rarely 
more than three or four are present, which tend to arrange themselves 
in rows. Most frequently they are found in the upper part of the 
vagina, especially growing from the anterior wall, though they may 
develop in the lateral walls, as well as in the lower part of the vagina. 
They vary in size from a pea to a hen's egg, though Yeit has reported 
a case in which the cyst reached the size of a foetal head. In most 
instances, however, they tend to grow slowly, and rarely reach a 
large size. 

Age appears to have no influence in their etiology, as they occur 
in virgins as well as in women who have borne children. Many the- 
ories have been advanced in explanation of the origin of these cysts. 
Huguier and Guerin thought they always grew from ' glands which 
were present in the walls of the vagina. In later years the tend- 
ency has been to regard all cysts of the vagina as having their origin 
in the remains of the Wolffian bodies. While a certain proportion of 
cysts no doubt originate in this manner, this theory fails to explain the 
origin of many cysts which develop in locations remote from such 
embryonal structures and which are very superficial. More recently 
Preuschen was able to demonstrate the actual existence of ductlike 
glands in a number of cases examined post-mortem, which were lined 
with columnar epithelial cells, from which fact he attributed to those 
cysts occurring in locations other than the anterior or lateral walls of 
the vagina a glandular origin. It is evident, therefore, that we must 
admit the glandular theory as explaining the origin of a certain propor- 
tion of smaller cysts, while most of the larger cysts develop from the 



NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 



225 



embryonal remains of the Wolffian bodies. In addition to these theo- 
ries, the possibility of dislocation of islands of epithelium which become 
embedded in the subcutaneous tissue, the result of trauma — as, for 
example, childbirth, or operations on the vagina, which afterward give 
rise to cysts — must always be borne in mind. Finally, dermoid cysts 
may develop in the wall of the vagina, usually in the recto-vaginal 
septum. 

Cysts of the vagina are rounded tumours, frequently biscuit-shaped, 
hemispherical, or fusiform, with tense elastic walls encroaching on the 
lumen of the vagina. Earely they may assume a polypoid shape, having 
protruded to such an 
extent as to form a 
pedicle (Fig. 80). 

The cyst wall 
varies much in thick- 
ness. In case the 
cyst is large the wall 
may be very thin 
and the contained 
fluid of a clear col- 
our, giving the cyst 
a bluish translucent 
appearance. 

The cyst con- 
tents are usually a 
thin, clear, yellow- 
ish, transparent 
fluid, though they 
may be viscid, tur- 
bid, and even of a 
dark - brown colour 
from the presence 
of disorganized 
blood. Microscopic- 
ally, the cyst con- 
tents are poor in 
organized elements, 
though occasionally 
there are to be found 
mucous corpuscles 

and groups of desquamated epithelial cells, cylindrical and squamous, 
together with cholesterin crystals and fatty detritus. Should the cyst 
become infected by pyogenic micro-organisms, suppuration takes place, 
and the contents will then consist largely of pus. 

Vaginal cysts are usually simple, though occasionally the remains 
of septa may still be observed. Earely, multilocular cysts have been 
described, Poupinel having met with one composed of fifteen small 
16 




Fig. 80 (Reed).— " They may assume a polypoid shape hav- 
ing protruded to such an extent as to form a pedicle."— 
Kothrock. 



226 A TEXT-BOOK OF GYNECOLOGY 

cysts. On microscopic examination the cyst wall is made up largely of 
fibrillary connective tissue, though in a certain number of cysts, smooth 
muscle fibres are present, more or less uniformly distributed. Great 
difference is noted in the epithelial lining of vaginal cysts. Usually 
it consists of a single layer of columnar epithelial cells, which may be 
ciliated. Occasionally the epithelial lining is polymorphous, consisting 
of cuboidal, cylindrical, and squamous cells, or the cylindrical cells may 
be entirely replaced by the squamous type. Veit attributes this change, 
especially when the cysts are large, to the pressure of the cyst contents. 
In a few instances invaginations of the epithelial lining into the cyst 
wall have been observed, the occurrence of which has been advanced as 
proof of the glandular origin of such cysts. 

Fibroids are the rarest of all neoplasms of the vagina. They are 
usually rounded, very rarely reaching a size larger than an orange, 
though tumours weighing as much as two pounds have been observed. 
They are almost invariably solitary and usually sessile, only exception- 
ally forming a pedicle. Their favourite location is the upper portion of 
the anterior vaginal wall. The etiology of these tumours is still obscure. 
They are most frequently met with in middle life, though they have 
been observed in children. Von Eecklinghausen has advanced the the- 
ory that these tumours are in reality adenomyomata, which have their 
origin in the remains of the Wolffian ducts, which view, however, still 
lacks confirmation. 

These tumours grow from the fibrous or muscular coat of the vagina, 
and are usually embedded in a fibrous capsule. Their histologic struc- 
ture is identical with that of fibroids of the uterus, consisting largely of 
connective-tissue bundles with a rather sparse intermixture of smooth 
muscle fibres. Striped muscle fibres are occasionally to be seen, in which 
case the tumour must be classed as sarcoma,, especially when occurring in 
children. The mucous membrane covering the tumours is usually in- 
tact, unless destroyed by pressure, when they will present ulcerated 
surfaces. Fibroids of the vagina may become cedematous, or gangrenous 
and sloughing, and may be cast off in this manner. Polypi are simply 
fibroids which have become pedunculated. They do not differ essen- 
tially in structure from fibroids. 

The treatment of benign neoplasms of the external genital organs 
represents some of the least difficult problems in surgery. Varicose 
tumours of the vulva, when they exist simply as enlargements of the 
veins and are not associated with extensive hypertrophy of the con- 
nective tissue, should be treated by obliteration of the veins. This to 
be effective must be done thoroughly. When the varices are restricted 
to the vulva, the larger trunks of the veins are easily detectable and 
may be tied by subcutaneous ligature. The ligatures should be applied 
at intervals along the same vessels, and the vessels themselves should be 
divided between the ligatures. The same principle of treatment may be 
applied to perivaginal varices, although the technique is rather more 
difficult. When pudendal varices are associated with extensive hyper- 



NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 227 

trophy, the hypertrophied area may be excised. In many of these 
cases the varicose condition of the external veins is but an index of the 
condition of all the veins surrounding the vagina and extending far up 
into the pelvic structures. The control of such extensive conditions 
is very difficult, if not impossible. Fibromyomata and cysts of either 
the vulva or vagina should be treated by extirpation. 

Malignant Neoplasms 

Malignant Neoplasms of the Pudendum.— Malignant tumours of the 
vulva are comparatively rare. If we remember how frequent these neo- 
plasms are in other parts of the female genital organs this must excite 
our comment. Schwartz collected 1,177 cases of carcinoma of the 
uterus and the vulva. Of these, only 30 cases belonged to the latter 
class; the rest were all carcinomata of the uterus. We are not, however, 
in a position to account for the comparative rarity of malignant neo- 
plasms of the pudendal organs. 

Carcinoma, which we will consider first, is much more frequent than 
sarcoma. 

Nothing definite is known as to any predisposing cause, except the 
advanced age of the patient. Winckel, who has seen 8, and collected 
from the literature 54, cases, found that 6 cases occurred in women 
under forty years; 16, between forty and fifty; 20, between fifty 
and sixty; and 20 cases in women over sixty years. It can not be 
shown that simple inflammatory processes or gonorrhoea and syphi- 
lis exert any predisposing influence with reference to the develop- 
ment of carcinoma of the vulva. The starting points for these 
tumours are the clitoris, labia majora and labia minora, the perineum, 
and rarely the glands of Bartholin. In the case of the latter the carci- 
noma has a glandular, in all other cases a squamous, epithelial-celled 
type. These tumours are generally characterized by an extensive new 
formation of tissue, by their inclination to early superficial ulceration, 
hard diffuse infiltration of the surrounding tissues, and involvement of 
the neighbouring lymph glands, particularly those in the inguinal re- 
gion. The glandular involvement, however, in some cases does not 
seem to supervene early. 

The carcinomata of the vulva, from certain macroscopic features, 
may be divided into several groups, which are, however, not distin- 
guished by fine microscopic differences. One form is characterized by 
a prominent tumour formation. The affected portion of the vagina 
presents a roundish tumor, generally of moderate size, usually not 
larger than a hen's egg or an apple. It is firm and hard in consistence, 
situated in the upper layers of the integument, and more or less mov- 
able on the subcutaneous tissues. The surface is formed by an epi- 
dermis, which has a tendency to form warty prominences and papillary 
excrescences. If these tumours are seen somewhat later they are not 
so freely movable and their surface has become ulcerated. A second 



228 A TEXT-BOOK OF GYNECOLOGY 

form takes on from the start the shape of a diffuse infiltration, which 
does not project materially above the level of the surrounding skin. On 
palpation of the neoplasm its site is found to be hard, and it is not freely 
movable, but, on the contrary, is firmly fixed to its surroundings. This 
variety likewise soon begins to ulcerate; its surface either shows a mass 
of shallow, uneven granulations, or a ragged tissue covered with a 
bloody, dirty, purulent exudate. The third form from the beginning 
has a marked tendency to ulceration, and presents a deep craterlike 
ulcer with hard, infiltrated, overhanging edges. 

Microscopically, carcinoma of the vulva presents a typical squamous 
epithelial-celled cancer. The epithelia of the stratum germinativum 
proliferate into the underlying connective tissue in the form of pegs or 
cylindrical masses, and these have a tendency to become branched. The 
proliferating cells speedily undergo cornification, and one therefore 
finds in carcinoma of the vulva epithelial pearls or " onion bodies " in 
great number and very typical in appearance. The younger epithelia, 
which have not undergone cornification and have preserved a columnar 
type, together with the somewhat tubular branched character of the 
cell nests, may, on superficial examination, create the impression of a 
glandular, tubular carcinoma. This impression is, however, erroneous, 
for carcinomata of the vulva are true squamous-celled neoplasms, not 
glandular carcinomata, but " cancroids/' 

When after removal of the original tumour a recurrence takes place, 
the latter frequently loses the characteristic structure of a cancroid, 
and presents a tissue composed of a fibrillar stroma with only small 
epithelial nests in which epithelial pearls are absent. There are fre- 
quently found in the neighbourhood of carcinoma of the vulva, near 
the primary tumour or near recurring metastasis, whitish patches of 
epidermis, which condition is known as leucoplahia. These spots 
microscopically show a thickening of the epidermis. They are not 
characteristic of carcinoma of the vulva, since they are also found in 
other conditions. 

Carcinoma of the vulvo-vaginal glands, of which a few cases have 
been reported, forms a hard tumour situated under the unchanged 
labium majus. Microscopic examination shows an alveolar carcinoma 
with remnants of normal glandular tissue of the organ. 

Carcinoma of the vulva after it is once well established generally 
spreads quite rapidly and has a tendency to grow around the urethra 
into the vaginal walls, into the pelvic fascia, and into the perineum. 
Involvement of the other labium majus from the opposite one originally 
affected has likewise been several times observed. The prognosis of 
carcinoma of the vulva appears to be somewhat better than that of 
cancer of the vagina, but recurrence and final death is the rule even 
after thorough removal. Goffe has reported a case of primary epithe- 
lioma of the clitoris followed by speedy lymphatic involvement. A sec- 
tion taken from a case of Whitacre's shows a typical microscopic picture 
of epithelioma of the clitoris (Fig. 81). 



NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 229 

Sarcoma of the vulva is very rare. The number of cases of this kind 
which have been reported is very small. These connective-tissue neo- 
plasms are, as a rule, very malignant, and there are few well-authen- 
ticated cases on record of permanent cure after the removal of a sar- 




Fig. 81. — "A section taken from a case of Whitacre's shows a typical microscopic picture 
of epithelioma of the clitoris.''— Herzog (page 228). 

coma of the pudendal organs. The sarcomata of this region usually 
present themselves as large spherical tumours arising from the labia, 
the clitoris, or the region of the external meatus of the urethra, or they 
may first be observed as deeply pigmented warts on the labia. There 
have been described round- and spindle-celled sarcoma, myxosarcoma, 
and melanosarcoma. The latter is the form most frequently observed 
on the vulva. Winckel, among ten thousand female patients, saw only 
two cases of sarcoma of the vulva. One case was that of a pregnant 
woman, twenty-five years old, with a tumour the size of a man's head, 
which was hanging down from the vulva, suspended on a pedicle the 
size of a child's arm. This tumour had not been very malignant, since 
it had been present and growing for eight } T ears. Its microscopic ex- 
amination showed it to be a round-celled sarcoma. AYinckePs second case 
was a myxosarcoma. Bruhn operated in two cases of fibrosarcoma, and 
claims that he obtained a permanent cure. "VTernitz reported a case of 
spindle-celled sarcoma. Eobb has described a nryxosarcoma. Ehren- 



230 



A TEXT-BOOK OF GYNECOLOGY 








dorfer has seen a small round-celled sarcoma springing from the anterior 
part of the meatus urinarius and protruding between the labia. Older 
reports have been furnished by G. Simon and a few others. There have 
been reported altogether about a dozen cases of this kind. Somewhat 
more numerous are the reports of cases of melanosarcoma. It is a well- 
known fact that the vulva is frequently the seat of pigmented spots and 
pigmented na?vi. These occasionally become the starting point of mela- 
notic sarcoma, 
which is generally 
of a most malignant 
type. Other mela- 
nosarcomata of this 
region do not begin 
in superficial pig- 
ment spots or nam, 
but in the deeper 
layers of the mucous 
membrane. They 
are first noticeable 
as a purplish spot, 
which spreads, be- 
comes deeper in col- 
our, and then as- 
sumes the shape of 
a simple wart or of 
a branched papil- 
lomatous growth. 
Haeckel reported a 
melanosarcoma of a 
deep bluish - black 
colour springing 
from the labia mi- 
nora and the cli- 
toris. Muller de- 
scribed a tumour of 
this kind arising 
from the clitoris. 
Most cases reported 
took their origin 
from the labia ma- 
jora. All the mela- 
nosarcomata of the 
vulva observed were 
characterized by a 
deep pigmentation; they were moderate in size. As a rule, they soon 
reappeared after removal and speedily led to the formation of multiple 
metastases. Sometimes general sarcomatosis, cachexia, and death, soon 



Fig. 82. — " Keed has removed a trilobular melanosarcoma from 
the meatus urinarius of a young girl." — Herzog (page 231). 



NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 



231 



follow operative procedures. Reed, however, has removed a trilobular 
melanosarcoma from the meatus urinarius of a young girl with complete 
success (Fig. 82). 

Histologically, these new growths generally are composed of round 
cells; occasionally spindle cells are found. The cells contain in their 
protoplasm a great 
amount of a 
brownish granular 
pigment, which is 
also found free 
between the cells 
composing the 
tumour (Fig. 83). 

Melano - carci- 
nomata of the 
vulva, likewise 
very malignant in 
character, have 
been described. 
Dr. Balfour Mar- 
shall has reported 
{Glasgow Medical 
Journal) the case 
of a widow, aged 
fifty -seven, in 
whom the site of 
the clitoris was 
occupied by a 

dark-bluish and bluish-red, slightly lobulated tumour, of the size of a 
small walnut. The growth was removed and was found to have origi- 
nated in the clitoris and praeputium clitoridis, being " a melanotic sar- 
coma with some hemorrhage into its substance/' Dr. Marshall was able 
to find records of only nineteen cases of sarcoma of the vulva, of which 
two started in the clitoris. 

Malignant tumours primarily situated elsewhere in the body not 
infrequently form metastases in the vulva. Carcinomata and sarcomata 
of the uterus lead to metastases in the pudendal organs, as also, at times, 
do malignant neoplasms of the ovaries and of the urinary bladder. 
Syncytioma malignum of the uterus, which so frequently forms metas- 
tases in the vagina, is also liable to form metastatic tumour masses in 
the vulva. Aschoff reports a case of syncytioma where the original 
tumour has made a metastasis in the left labium ma jus. 

Malignant Neoplasms of the Vagina. — (a) Sarcoma in Childhood. — 
Primary sarcoma of the vagina occurs at any period, in infancy as well as 
in adult life, and, since there is a very great difference in its appear- 
ance and mode of development in the two ages, allowing a sharp subdivi- 
sion, it is customary among writers to treat these subdivisions separately. 




Fig. 83 (Reed). — " A brownish granular pigment, which is found 
free between the cells composing the tumour." — Hekzog. 



232 A TEXT-BOOK OF GYNECOLOGY 

In children, as in adults, it is a rare disease, and usually manifests 
itself during the first two or three years of life. Granicher observed 
a case in a newborn child, which, however, advanced very slowly and 
did not prove fatal until the seventh year of life. 

Sarcoma in children commonly appears in the form of polypoid or 
grapelike protrusions, usually springing from the anterior wall of the 
vagina. In the beginning, the tumour is rounded or hemispherical 
with a broad base, but it tends to become polypoid as the disease ad- 
vances. It is generally of a cherry-red colour, but it may be dark brown 
if very vascular. Soon the surrounding mucous membrane becomes 
infiltrated and here and there in the surrounding structure secondary 
nodules begin to develop. Sarcoma shows a marked tendency to infil- 
trate the vesico-vaginal septum and invade the bladder, and may, from 
pressure on the urethra, or infiltration of the neck of the bladder, cause 
urinary stasis with resulting dilatation of the bladder and nephydro- 
sis. In advanced cases the tumour is very prone to undergo ulceration 
or necrosis with resulting infection of the genito-urinary tract, which 
ultimately reaches the kidneys, terminating in pyelonephritis. Earely, 
the infection may extend to the uterus, and even to the peritoneal 
cavity. The recto-vaginal septum may also be involved. 

Metastasis to distant parts of the body has not been observed, 
though regional metastasis to the inguinal glands and ovary has been 
met with. 

Histologically, the tumour may consist largely of connective tissue, 
or it may assume the type of myxosarcoma. The sarcomatous ele- 
ment may consist of round or spindle cells, or both may be present. 
Occasionally giant cells are observed, and not infrequently striped 
muscle fibres are to be seen. According to Kolisko, striped muscle 
fibres are usually present, but other observers have failed to confirm 
this view. 

The etiology is unknown. However, since it begins in infant life, 
Veit (Handbook, p. 355) regards it as probable that in some cases at 
least it is congenital. Kolisko also regards the presence of striped 
muscle fibre as evidence of congenital origin. 

(b) Sarcoma in Adults. — Primary sarcoma of the vagina occur- 
ring in adults belongs to the rarer tumours. Up to the present time 
but thirty-one cases have been reported. They have been observed be- 
tween the ages of fifteen and eighty-two, though the larger proportion 
has occurred in persons under forty years of age. They most frequently 
grow from the anterior wall and are rather more frequent in the lower 
third of the vagina. They appear as more or less circumscribed 
tumours, which is the most common form, less frequently as a diffuse 
infiltration of the mucous membrane of the vagina, which tends to 
ulceration. In the circumscribed form the tumour is usually smooth, 
rounded or hemispherical in shape, and sometimes is encapsulated. 
The integrity of the mucous membrane covering the tumour is usually 
maintained until pressure from its increasing size produces ulceration. 



NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 233 

Metastases to distant parts of the body have been observed, notably to 
the lungs and skin. 

Of the etiology of these tumours we know as little as of sarcoma 
in general. They usually have their origin in the perivaginal connective 
tissue, or in the submucosa. Occasionally they originate in the blood 
or lymph vessels, when they are termed endothelioma. Cases of this 
kind have been reported by Klein, Kalustow, and Waldstein. 

Histologically, sarcoma of the vagina in the adult may consist of 
spindle, round, or mixed cells, and occasionally giant cells are present. 
Sarcoma of the vagina is especially characterized by the tendency to 
recurrence after removal, and, according to Jung (Monatsschrift fur 
Geburtshiilfe und Gynakologie, Bd. ix), only three cases are on record 
which have passed without recurrence a sufficient length of time after 
removal to be denominated cured. 

The vagina may be secondarily involved by sarcoma, which pri- 
marily has its seat in some other region of the body, as, for example, 
the uterus. Especially is this so in sarcoma of the cervix, where sec- 
ondary involvement of the vagina is almost the rule. 

(c) Carcinoma. — Primary carcinoma of the vagina is not common. 
Gurlt, among 59,600 patients, found 114 cases. Unlike sarcoma, it is 
a disease of later life, and has not been met with under the age of 
twenty-five. It appears mostly as an ulcerating excrescence, with 
sharply circumscribed borders, and is most frequently located on the 
upper portion of the posterior vaginal wall. The surrounding mucous 
membrane is usually involved in a catarrhal inflammation, and is fre- 
quently eroded and bleeds on the slightest touch. Not infrequently 
a marked thickening of the mucous membrane in the neighbourhood 
of the carcinomatous involvement appears as a diffuse infiltration, 
manifested as a thickening of the vaginal walls encroaching upon the 
lumen of the vagina. At first it may involve only a segment of the 
vagina, encircling its entire circumference like a band. In these cases 
ulceration is only observed after a considerable length of time. In the 
diffuse variety the growth is at first slow, but eventually infiltration 
of the perivaginal connective tissue takes place and the growth may 
invade the bladder or rectum, or extend into the parametrium, involv- 
ing secondarily the iliac and retroperitoneal glands, or, in case the 
growth is confined to the lower third of the vagina, the inguinal glands 
may become involved. 

The etiology is obscure. In a few instances it has been observed 
to develop at the point of pressure from pessaries, especially where 
their long-continued use has caused ulceration. These cases have 
many points in common with carcinoma of the skin, which some- 
times develops in the border of indolent ulcers. In the present state 
of our knowledge concerning the etiology of carcinoma, it is difficult 
to say just what influence the pessary has had as an exciting cause 
of the carcinoma, and whether the irritation following its use, or the 
ulceration by producing an atrium of infection, has been chiefly 



234 



A TEXT-BOOK OF GYNECOLOGY 



instrumental we do not know. Microscopically, primary carcinoma of 
the vagina presents the characteristics of carcinoma growing from the 
skin and consists of squamous epithelial cells. 

Secondary Carcinoma. — Secondary carcinoma of the vagina is of 
much more frequent occurrence, and may result from direct exten- 
sion or metastasis. Most frequently it is secondary to carcinoma 
of the uterus, especially to involvement of the portio vaginalis. In 
carcinoma of the hody of the uterus the vagina may he secondarily 
involved hy implantation metastasis. Carcinoma of the rectum or 
bladder may secondarily invade the vagina, and occasionally metas- 
tasis to the vagina has been observed to follow primary carcinoma 
of the ovary. Secondary carcinoma of the vagina partakes of the 
nature of the primary growth and is identical in its histologic 
structure. 

Treatment of malignant neoplasms of the external organs of gen- 
eration resolves itself into radical and palliative. The radical treatment 
consists in the extirpation of the malignant growth whenever it is so 
situated that its removal can be accomplished with reasonable safety 
to the life of the patient and with a reasonable prospect of complete- 
ness. Malignant tumours of the vulvo-vaginal glands, those involving 
either labium, the vagina, or the clitoris, should be freely excised, care 

being taken to dissect out all 
indurated neighbouring lym- 
phatics. 

Clitoridectomy, or excision 
of the clitoris, may be de- 
manded for the cure of either 
malignant or tuberculous dis- 
ease of that body; also for the 
removal of a malformed or hy- 
pertrophied clitoris, or for the 
relief of extreme nervous dis- 
turbances due to hyperes- 
thesia of that organ. The 
technique of the operation is 
as follows: Divide the tissues 
around the base of the gland 
by means of scissors, one blade 
of which is inserted beneath 
the integument, at the inner 
duplication of the preputial 
fold, and is carried entirely 
round the organ; the prepuce 
is then slit toward the pubis (Fig. 84); the clitoris is dissected out, but, 
before being excised, its base is clamped by a slender-bladed Kocher 
hemostatic forceps (Fig. 85); after which it is cut away, the vessels 
being controlled by ligatures. The flaps are approximated by buried 




Fig. 84. — " The prepuce is then slit toward the 
pubis." — Reed. 



NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 



235 



animal sutures and the margins of the wound are elosed by the inter- 
eutaneous method. (See Figs. 38, 39.) 

Extirpation of the vagina is sometimes practised in cases of primary 
carcinoma or of tuberculosis of that canal. Very satisfactory reports of 
the operation have been made by Olshausen, Diihrssen, Martin (of 
Greifswald). and others. In 
the performance of this oper- 
ation it may be necessary, as 
a preliminary step, in cases 
of narrow or indurated va- 
gina^ to incise the perineum, 
or even to carry the incision 
entirely through the peri- 
neum, round the anus, and 
up to the coccyx. As a rule, 
however, the operation may 
be done, as Martin directs, by 
making a preliminary inci- 
sion round the hymenal ring 
at the introitus vagina?. Af- 
ter this has been done, but 
little difficulty is experienced 
in enucleating the vagina by 
means of the finger, separat- 
ing the entire canal from its 
underlying connective tissue 
clear to its juncture with the 
cervix. If the disease has not 

gone beneath the mucous membrane, the resulting disturbance of the 
blood vessels will not be so marked as to occasion serious difficulty in 
controlling the hemorrhage. If, however, the incision must be made 
through the perineum, round the rectum, and up to the coccyx, the 
hemorrhage from the hemorrhoidal plexus may be controlled only 
with some difficulty. After the vagina has been enucleated in the 
manner indicated, the remainder of the operation consists in the re- 
moval of the uterus and adnexa according to the technique described 
in Vaginal Hysterectomy. The proposition has been made by P. Miiller 
to extirpate the vagina, leaving the senile uterus in situ; but as even 
the senile uterus is the source of some secretion which will accumulate 
above the tract of the vagina, which now becomes occluded, it is essen- 
tial that even in these cases the uterus should be removed. Partial 
extirpation of the vagina has been practised by Fritsch and Asch, but 
the results have not been satisfactory. The method of Martin, as 
before described, is probably the safer, the operation being concluded 
by drawing down the peritoneum and stitching it all round at the 
introitus. After this step has been taken the vulvar orifice closes itself 
by transverse obliteration. 




Fig. 85. — "The clitoris is dissected out, but before 
being excised its base is clamped." — Reed (p. 234). 



236 A TEXT-BOOK OF GYNECOLOGY 

The palliative treatment of malignant neoplasms of the external 
genital organs consists in making the patient as comfortable as pos- 
sible during the persistence of the disease, and should be adopted as a 
line of practice only in cases that are either awaiting operation, or that 
have ceased to be suited to it in consequence of the extension of the 
disease. Of the latter class may be mentioned as examples car- 
cinoma of the vagina invading and penetrating the recto-vaginal sep- 
tum, thereby causing a recto-vaginal fistula, or other cases, again, in 
which the disease has perforated the bladder. These are distinctly 
hopeless conditions, entirely beyond the reach of surgical art, their 
comfort, or the little that may be secured for them, depending on vari- 
ous palliative measures. Cleanliness is of the first consideration; 
douches of lysol or creolin are cleansing, antiseptic, and are better 
borne than the more irritating solutions of either carbolic acid or the 
mercuric bichloride. Excoriated surfaces may be dressed with steril- 
ized white vaseline or other oleaginous product, a little lysol or creolin 
being incorporated with this agent if desired. Opiates in the form of 
rectal suppositories, or hypodermic injections of morphine, should be 
given whenever they are not contraindicated by the idiosyncrasy of the 
patient. These are cases for euthanasia. 



CHAPTER XX 

DISPLACEMENTS OF THE VAGINA 

The vagina — Varieties of displacements — Cystocele — Rectocele — Urethrocele — Col- 
porrhaphy, anterior and posterior. 



The vagina is a canal lined with a mucous membrane partaking 
largely of the histologic elements of the integument, and is surrounded 
by some muscular strias that are designated as the sphincter vaginae 
muscle. The tube thus constituted extends from the vulva to the 

uterus and is sur- 
rounded by more or 
less loose cellular tis- 
sue. It is slightly 
curved, being concave 
anteriorly and convex 
posteriorly. It is held 
in position, not alone 
by its attachment to 
its surrounding cellu- 
lar tissue, but more 
particularly by its at- 
tachment to the 
uterus and the pelvic 
diaphragm, and by the 
support which it de- 
rives from the perine- 
um. This canal is 
liable, in whole or in 
part, to displacement. 
TJpivard displacement 
may occur, as in the 
case of a large fibroid 
tumour, the growth of 
which carries it above 
the pelvic brim, caus- 
ing it to drag the vagina upward. This upward displacement may occur 
to such a degree as to exercise more or less tension, even upon the lower 
segment of the canal. Downward displacement, or a prolapse of the 
vagina or some part of it, is the condition more frequently encoun- 

237 




Fig. 86. — "Sacculations may occur from the urethra, a con- 
dition called urethrocele." — Eeed (page 238). 



238 



A TEXT-BOOK OF GYNECOLOGY 



tered. The causes of prolapse of the vagina, or of one or the other 
or both of its walls, may exist either in the pelvic diaphragm or in 
the pelvic floor. Weakness of the pelvic diaphragm — a condition which 
depends upon the loss of the retentive power of the pelvic fascia — is 
generally manifested primarily by descensus uteri. When this condi- 
tion occurs it is always and necessarily associated with more or less 
descent of, at least, the upper segment of the vagina. This is gen- 
erally specially marked in relaxation and descent of the floor of 
Douglas's pouch. Occasionally this condition of the pelvic diaphragm, 
with its associated hysteroptosis, is sufficient to cause more or less 
descent of the anterior vaginal wall. Eelaxation of the pelvic floor 
or the enlargement of the vaginal orifice by laceration of the perineum 
may, by removing the support from the superimposed structures, in- 
duce a similar prolapse of the vaginal wall. When the anterior vagi- 
nal wall folds inward it forms a sort of pouch from the bladder and 
is, therefore, designated a cystocele ; when the posterior wall folds into 

the vagina and forms 
a pouch from the rec- 
tum, the condition is 
designated a rectocele 
(Figs. 86, 87). Simi- 
lar sacculations may 
occur from the ure- 
thra — a condition 
called urethrocele 
(Fig. 86). 

The pathology of 
these displacements, 
particularly of cysto- 
cele and rectocele, 
shows them as con- 
sisting essentially in 
an atrophy of the 
perivaginal muscu- 
laris, with a corre- 
sponding loss of its 
retentive power; and 
in a distention with 
resulting redundancy 
of the vaginal mu- 
cosa. The symptoms 
of these sacculations 
are very characteris- 
tic. In cystocele the patient is conscious of more or less distention of the 
vaginal orifice when she attempts to urinate; she experiences difficulty 
in completely emptying the bladder, often being forced to push that 
viscus upward with the finger before being able to empty it. When 




Fig. 87. — " There is always more or less residual urine remain- 
ing in the adventitious pouch." — Reed (page 239). 



DISPLACEMENTS OF THE VAGINA 



239 



this sacculation is extreme she may be unable to completely empty 
the bladder, even though she assists herself by the means indicated; 
under these circumstances there is always more or less residual urine 
remaining in the adventitious pouch (Fig. 87) — a condition which 
sooner or later results 
in inflammation of 
the bladder, with the 
usual pain and tenes- 
mus. On inspection, 
a globular mass, which 
can be readily re- 
placed by the finger 
and which increases 
in size and tension if 
the patient strains, 
will be seen present- 
ing at the vulvar ori- 
fice. A curved sound, 
introduced through 
the urethra into the 
bladder, can be readily 
felt on the inside of 
this pouch, thus ren- 
dering certain the di- 
agnosis of cystocele. 
In rectocele the pa- 
tient when straining 
at stool feels as if she 
were about to defecate 
through the vagina, 
and finds it necessary 
sometimes to replace 
the protruding mass 
before she can empty 
the rectum. If the 
finger is introduced 
into the rectum in 
such a case as this it 
can be brought for- 
ward into the pro- 
truding pouch, which 

presents at the vulvar orifice as a globular mass, having the colour 
of the vagina and presenting the half-obliterated rugae upon its sur- 
face. If the patient strains or coughs the protruding mass increases 
in both size and tension. 

The treatment of displacements of the vagina consists primarily in 
correcting, so far as possible, the causative conditions. When these 




Fig. 88. — " . . . Transverse denudations, so that the resulting 
line of approximation may be coincident with the normal 
folds of the vagina. 1 ' — Keed (page 242). 



240 



A TEXT-BOOK OF GYNECOLOGY 




exist in the pelvic diaphragm, as when they depend upon prolapse 
of the uterus, the remedy is to be found in relieving the vagina of 
the abnormal pressure. This is generally accomplished by one or 
other of the recognised operations for the cure of prolapsus uteri. 
(See Surgical Treatment of Uterine Displacements.) Pessaries are, 
as a rule, more mischievous than otherwise; although their use may 

afford the patient a 
sense of temporary 
comfort. Those pes- 
saries, however, 
which by their con- 
struction distend the 
vagina, or impinge 
forcibly upon any 
part of its walls, 
have a tendency to 
dilate the canal still 
further and render 
the original mischief 
more troublesome. In 
the place of pessaries 
it is usually better to 
employ tamponade 
with some astrin- 
gent and antiseptic 
medicament. In 
cases of extreme rec- 
tocele or cystocele, 
or both, either com- 
bined or not with 
complete procidentia 
uteri, temporary 
comfort is derived 
from wearing a firm 
perineal support. 
Protruding vaginal 
surfaces frequently 
become excoriated, 
in which case they 
should be treated by 
careful cleansing and 
emollient applica- 
tions. Such methods 
of treatment are, 
however, but tentative, cure depending upon such correction of the un- 
derlying cause and acquired morbid changes as can be effected only by 
surgical intervention. If the condition depends upon relaxation or en- 






RJHQFKINS 




Pig. 89. — " There are cases, however, in which the anterior 
sacculation of the recto-vaginal septum exists without ap- 
parent injury to either layer of the pelvic floor." — Keed 
(page 242). 



DISPLACEMENTS OF THE VAGINA 



241 



largement of the vaginal outlet, the latter resulting from laceration of 
the perineum or injury to the pelvic floor, the proper remedy is to be 
found in a restoration of the perineum or pelvic floor, associated, it may 
be, with a narrowing of 




the lower segment of the 
vagina. (See Perineor- 
rhaphy.) This may need 
to be associated with the 
operation for either cysto- 
cele or rectocele, or both. 
The operation for cys- 
tocele consists in narrow- 
ing the anterior wall of 
the vagina and, conse- 
quently, is called anterior 
colporrhaphy. It is ac- 
complished, in general 
terms, by removing a disk 
of the redundant mucous 
membrane from the pro- 
truding vaginal wall, and 
in approximating the 
margins of the wound. 
The disk of membrane 
thus removed may be el- 
liptical or circular in 
form, and may vary in 
dimensions according to 
the size of the cystocele. 
Fritsch removes a circular 
piece of membrane, from 
an inch to an inch and a 
half in diameter, from 
the most prominent part 
of the presenting pouch; 
this denudation is then 

encircled by a single tobacco-pouch suture which is drawn up and 
tied, the cystic wall being pushed upward into the bladder as the 
suture is tightened. The technique is very simple, and in cases of 
small cystocele the operation is very effective. It is not practicable, 
however, in very large protrusions, in which there is marked redun- 
dancy of tissue. In such cases it is better to remove an ellipse of tissue 
closing the wound by careful linear approximation of its margins. 
Operators differ as to the direction that should be given to the long 
axis of this elliptical denudation. They formerly made the long axis 
of the denudation coincident with the long axis of the vagina; 
but an increasing number of later operators prefer to make one, or 
17 




90.- 



In such cases the vaginal wall should be 
denuded." — Eeed (page 242). 



242 A TEXT-BOOK OF GYNECOLOGY 

perhaps two, transverse denudations, so that the resulting line of 
approximation may be coincident with the normal folds of the vagina 
(Fig. 88). Experience seems to warrant the latter innovation, as 
there is less tendency to retraction and the results seem to be more 
permanent. The closure can be effected either by the interrupted, 
or the buried animal, suture. When the interrupted suture is em- 
ployed it should be removed on the eighth or ninth day. (See Opera- 
tive Treatment of Prolapsus Uteri.) 

The operation for rectocele consists in narrowing the posterior wall 
of the vagina and, consequently, is called posterior colporrhaphy. It 
differs from the operation on the anterior wall, chiefly because rectocele 
as a rule exists as a complication of such conditions as call for the 
repair of the perineum or the restoration of the pelvic floor. The re- 
dundancy of tissue is reduced by removing one or more ellipses trans- 
versely from the vaginal wall and approximating the edges with inter- 
rupted sutures. (See Perineorrhaphy, Fig. 107). There are cases, how- 
ever, in which the anterior sacculation of the recto-vaginal septum 
exists without apparent injury to either layer of the pelvic floor (Fig. 
89). In such cases the vaginal wall should be denuded as indicated in 
Fig. 90, which is drawn from a patient in whom the conditions varied 
slightly from those in the case just mentioned. The mucous margins are 
then approximated by interrupted sutures, beginning first with one tri- 
angle, then with the other, thus forming the expanded arms of a Y. 
The remaining area is then approximated by passing the interrupted 
sutures from side to side. 



CHAPTER XXI 
THE VTJLVO-VAGINAL GLAND 

Anatomv — Gonorrhoea! infection — Abscess — Cysts — Carcinoma. 



The vulvovaginal glands, or glands of Bartholin, are two small 
rounded or oval bodies from 15 to 20 millimetres in length, varying 
greatly in size and shape, and situated in the posterior third of the 
labia majora. one on either side of the lower end of the vagina, 
immediately below the bulb and in front of and near the upper 

margin of the perineal septum 

_____ . _ 



racemose glands 



(Fig. 91). 

They are 
the acini of which are lined 
by a single layer of high co- 
lumnar epithelial cells with 
basal nuclei. They secrete a 
muco-serous fluid which is 
emptied through two slender 
ducts of about 2 centimetres in 
length and terminating in 
small openings in the vestibule 
about 1.5 centimetre from the 
posterior median line just out- 
side the hymen. These ducts 
are lined by low cuboidal epi- 
thelial cells and their mouths 
are plainly visible on close in- 
spection, being of sufficient 
size to admit the passage of a 
fine probe. Functionally, the 
secretion of these glands serves 
to moisten the mucous mem- 
brane of the vestibule, and dur- 
ing sexual excitation or coitus 

it is discharged in considerable quantities. These glands become fully 
developed at the age of puberty, and maintain their full function until 
the climacteric, when they begin slowly to undergo atrophy and their 
function gradually ceases. The location of the mouths of these ducts 
renders them peculiarly liable to infection which may, by extension 

243 




Fig. 91. — " The vulvovaginal glands . . . are 
situated in the posterior third of the labia 
majora." — Rothrock. 



244 A TEXT-BOOK OF GYNECOLOGY 

through the duct, involve the gland and result in a series of inflamma- 
tory conditions constituting the chief diseases to which it is liable. 

Inflammation must be regarded as invariably due to bacterial infec- 
tion, and cases apparently the result of trauma, as for example those 
following on childbirth, are now generally explained by the pre- 
existence of pathogenic bacteria in the duct, the trauma having served 
merely to afford an atrium of infection. While various bacterial flora 
of the vulva may gain entrance to these ducts, inflammation is almost 
invariably of gonorrheal origin. The one possible exception to this 
is the staphylococcus, which, it appears, may produce inflammation 
either alone or in association with the gonococcus. All other bacteria, 
therefore, which may at times be present, must be regarded in the 
light of secondary invaders. 

Pure gonorrheal inflammation usually remains confined to the 
ducts, rarely involving the parenchyma of the gland, and then only 
slightly. 

Gonorrhoeal Infection of the Ducts. — Infection of the ducts may 
occur directly, but in the majority of cases it is secondary to infection 
of other portions of the genital tract. A well-developed case of gonor- 
rheal inflammation of the vulvo-vaginal gland has been observed four- 
teen days after exposure to infection (Bumm), but this is exceptional, 
and frequently weeks or months may elapse before the mouths of the 
ducts become infected although constantly bathed meanwhile with 
vulvar or vaginal secretions. In most instances both ducts are in- 
volved, frequently from the beginning, but almost invariably in cases 
of long standing. The ducts are usually involved throughout their 
entire length, though oftentimes the involvement is not uniform 
throughout, but some portions of the duct are more severely attacked 
than others. 

To C. Herbert (Inaugural Dissertation, Leipsic, 1893) we are in- 
debted for a description of the histological changes which take place 
in gonorrheal inflammation of the gland and its duct. 

They consist essentially of desquamation of the epithelial cells, 
with a small round-celled infiltration of the intercellular substance 
and subepithelial connective tissue. 

At first the epithelium lining the duct becomes swollen, and even- 
tually loosened, by the infiltration of leucocytes, then desquamation 
begins. In cases of long standing, the desquamated epithelial cells are 
replaced by cells more cuboidal in character, often approaching the 
squamous type. The lumen of the duct will be found filled with pus 
and desquamated epithelial cells in which gonococci may be demon- 
strated. The gonococci may penetrate to the subepithelial connective 
tissue but are not found in the infiltration cells themselves. 

Gonorrheal inflammation of the ducts either begins as a chronic 
process, or, after a brief and ill-defined acute stage, becomes chronic. 
It may persist for months, and even years, an ever-fruitful source 
of infection, and, indeed, together with infection of Skene's glands, 



THE VULVO-VAGIXAL GLAND 245 

may constitute the only points of localization of the infection in 
women. It usually occurs some time during sexually active life, 
though. Fischer (Deutsche medicinische TYcclienschrift, 1895) has observed 
it in children. 

Symptoms. — In the beginning, gonorrhoea of the ducts gives rise 
to few or no symptoms, so that the patient may be totally unconscious 
of its presence. Occasionally, there is a sensation of itching and burn- 
ing and perhaps some slight sensitiveness on pressure, or the patient 
may complain of a dull pain increased on walking or sitting. 

These symptoms when they occur are of short duration, and the 
patient may be conscious of nothing more than a slight muco-puru- 
lent discharge. Even this is often so slight as to escape notice. 

On examination, if the labia are separated so as to bring the mouths 
of the ducts into view, these appear, in cases of recent infection, in 
the form of dark-red, glistening, moist, spots resembling small ulcers, 
this appearance being due to ectropion of the inflamed and swollen 
mucous membrane lining the duct. 

If pressure is made along the course of the duct, a thin yellowish 
pus may be made to exude from its mouth, often in considerable quan- 
tities, which examination with the microscope shows to consist of pus 
and desquamated epithelial cells in which gonococci may be demon- 
strated in large numbers. 

Occasionally a nodular swelling, or induration, due to an infiltra- 
tion of the subepithelial connective tissue by small round cells, may 
be felt along the course of the duct. 

"When the disease becomes chronic, similar signs may be observed 
though less pronounced. The secretion now becomes more mucoid 
in character, and while gonococci may still be demonstrated they are 
present in diminished numbers. 

Frequently the only remaining sign of infection is the appear- 
ance of the mouths of the ducts, which Sanger has compared with flea- 
bites and has named "macula? gonorrhoea?," since he regards them 
as an infallible sign of gonorrhoea. 

Gonorrhoeal inflammation of the ducts may terminate in abscess of 
the glands or in cyst formation, and these two conditions constitute 
the chief diseases of the vulvo-vaginal glands, inasmuch as gonorrhoea! 
disease of the ducts is so devoid of symptoms that the patient is seldom 
conscious of its existence, and frequently it is only discovered by the 
examination of a physician. 

Abscess. — Inflammation of the parenchyma is invariably due to in- 
fection by pyogenic bacteria, most frequently the Staphylococcus pyo- 
genes aureus, occasionally the Staphylococcus pyogenes alius, either in 
association with the gonococcus or alone, and in a few instances the 
Streptococcus pyogenes has been found present (Dujon). In addition 
to these, various other bacteria are sometimes present in the pus. fre- 
quently the Bacterium coli commune; and in one case of relapsing 
abscess, examined by Eothrock, the Bacillus pyocyaneus was present, 



24:6 A TEXT-BOOK OF GYNECOLOGY 

together with the Staphylococcus pyogenes aureus and other undeter- 
mined bacilli. 

The pus has frequently a foul odour similar to that so often met 
with in abscesses occurring about the anus, and in all probability due 
to the associated presence of the colon bacillus or putrefactive bacteria. 

Inflammation of the gland is almost always secondary to inflam- 
mation of the duct, though Kothrock recalls a case which had been 
under observation for some time, in which there was no evidence of 
disease of the ducts, old or recent. In this case the Staphylococcus 
pyogenes aureus was found in pure culture and no gonococci were 
demonstrable in the pus. 

Abscess of the gland may occur at any stage in the progress of 
disease in the duct, and, according to Bumm, it occurs in about one 
third of all cases of gonorrhceal infection of the duct. It is frequently 
met with in prostitutes, in whom gonorrhceal infection is unusually 
common. In this class of patients the traumatism incident to the 
abuse of coitus seems to be a fruitful exciting cause. 

Not infrequently it is met with immediately following menstrua- 
tion in the absence of any history of traumatism. 

Abscess usually develops unilaterally and may occur on either side, 
appearing to have no predilection for one side over the other. In 
case the disease runs a very acute course, the parenchyma of the gland 
is quickly destroyed, and the infection may pass through the mem- 
brana propria into the surrounding cellular tissue, with a resulting 
phlegmon which terminates in suppuration with the formation of an 
abscess. Usually, however, the inflammation runs a less acute course 
and remains confined to the capsule of the gland, which quickly be- 
comes distended with pus. In such cases the cellular tissue outside 
the gland becomes cedematous, and this in a large measure accounts 
for the swelling which is present. 

Symptoms. — Abscess of the vulvo-vaginal gland as a rule begins 
abruptly, and manifests itself by swelling of the labia majora accom- 
panied by the usual signs of acute inflammation — redness, heat, and 
pain. On examination, there may be felt in the posterior third of the 
labia majora, and often extending into the vagina, an irregular-shaped 
swelling the size of a pigeon's egg, and extremely sensitive on pressure. 
After a few days, during which the symptoms increase in severity, the 
swelling becomes boggy indicating beginning suppuration, and fluc- 
tuation may soon be felt. During this time the patient will usually 
find locomotion difficult on account of the swelling. The pain will 
have increased in severity, and have become throbbing in character. 
In severe cases there is usually a slight elevation of temperature reach- 
ing 101° or 102° F., and the onset of suppuration may be ushered in 
by a chill. There is usually some swelling of the inguinal glands on 
the affected side, which always indicates infection by pyogenic bac- 
teria, as it is never present in pure gonorrhceal infection (Sanger). 
With the accumulation of pus, a gradual thinning of the skin and sub- 



THE VULVO-VAGINAL GLAND 247 

cutaneous tissue takes place, and the abscess, if not opened, points and 
ruptures spontaneously. 

Perforation usually takes place on the inner surface of the labia 
majora, but the pus may be conducted forward between the layers of 
the ischiopubic fascia, and point in the fold between the labia majora 
and labia minora. In some cases, the abscess may be evacuated through 
the duct by pressure made in that direction; but this is exceptional, as 
the duct is usually occluded, or at least does not communicate with 
the main abscess cavity. Earely the pus may burrow, and the abscess 
may be evacuated through the perineum, or even into the rectum with 
resulting fistulse. The pus may be yellow, dirty-green, or chocolate- 
coloured from altered blood. It frequently has a foul odour, and may 
contain gangrenous shreds. 

Well-defined abscesses are usually sharply limited by a thick pyo- 
genic membrane, the inner surface of which may be smooth, or irregu- 
lar from necrotic shreds, or from trabeculae-like septa which separate 
the lobes of the gland. Inflammation of the vulvo-vaginal gland almost 
invariably terminates in suppuration, though occasionally cases are 
met with in which it is characterized by marked induration with little 
tendency to the accumulation of pus. In these cases, the induration 
may remain for a long time, and may serve as a focus of infection for 
renewed attacks under the stimulus of traumatism. 

Cysts. — Cysts of the vulvo-vaginal gland are invariably the result 
of occlusion of the duct, and are therefore retention cysts. 

The vast majority are secondary to gonorrhceal infection of the 
duct. According to Sanger, they are an almost certain indication of 
pre-existing gonorrhoea, while Winter maintains that they may result 
from occlusion of the duct by traumatism, as, for example, in child- 
birth. 

Cysts may be located in the duct or in the gland. Those of the 
duct are small, superficial, and may remain for a long time without 
the patient's knowledge, being only discovered accidentally by exami- 
nation. They are situated in the lower part of the labia majora and 
at first are fusiform, but later they tend to become spherical. Cysts 
of the gland proper are larger, and are more deeply situated. From 
the beginning, they are spherical in shape, and may develop in one 
lobule, or the entire gland may be converted into a cyst. 

The wall of the cyst is usually thin and consists of connective tis- 
sue, and, occasionally, the remains of the epithelial lining of the gland 
may still be observed. 

The cyst contents vary in character ranging from a thin clear 
serous fluid, to a thick, tenacious, or colloidlike, accumulation, vary- 
ing in colour, sometimes clear or yellow, and, again, brown or chocolate 
coloured from the presence of altered blood. 

Microscopically, they may contain blood corpuscles, leucocytes, 
epithelial cells, cholesterin crystals, and detritus, and frequently the 
presence of gonococci may be demonstrated. 



248 A TEXT-BOOK OF GYNECOLOGY 

As a rule, the older the cyst, the clearer will be its contents. In 
case the duct is not altogether occluded, pressure over the cyst may 
force out some of its contents, and occasionally cysts are met with 
which empty themselves spontaneously or during coitus, and which 
refill again after a time. In a few instances, cysts have been described 
which contained a fatty substance similar to that of sebaceous cysts. 
It is probable, however, that these were cysts which had their origin 
in the sebaceous glands of the vulva. 

Occasionally, cysts are met with which contain gonorrheal pus, the 
result of occlusion of the duct. Such collections have been termed 
pseudo-abscesses, as the usual signs of acute inflammation, such as are 
observed in staphylococcus infection, are wanting, except perhaps slight 
swelling which is due to oedema. 

Cysts of the vulvo-vaginal glands may become secondarily infected 
by pyogenic bacteria, following on which, suppuration ensues and 
the cyst is transformed into an abscess, with the usual accompanying 
symptoms. 

Cysts of the gland proper rarely reach a size as large as a hen's 
egg; and those especially large ones which have been described, the 
contents of which were clear and limpid, were probably in reality vagi- 
nal cysts from the remains of Gartner's ducts. 

Treatment. — Gonorrhoea of the ducts usually runs a very chronic 
course if left to itself, and, owing to the difficulty of access of 
the localized points of infection, often proves most obstinate to 
treatment. 

First of all, cleanliness of the external genitals should be secured 
by antiseptic douches. The duct should be systematically evacuated 
each day by gentle pressure made along its course from within out- 
ward, after which an application of an 8-per-cent solution of nitrate 
of silver should be made by means of cotton wrapped on a slender 
probe. Good results also follow the use of a 2-per-cent solution of 
formalin applied in the same manner. When the lumen of the duct 
is very narrow or obliterated, it is sometimes best to lay it open along 
its entire length, and this is most conveniently done by a Weber's 
canaliculus knife such as is employed by oculists for division of stric- 
ture of the lachrymal duct. 

When the duct has been laid open it should be washed out with 
an antiseptic solution, after which, either of the above-mentioned 
solutions of silver nitrate or formalin may be applied. 

Pozzi recommends the application of a 2-per-cent solution of 
chloride of zinc or cauterization by a crayon of nitrate of silver, while 
others recommend cauterization with pure carbolic acid. 

Inflammation of the gland is to be treated as is acute inflammation 
elsewhere, namely by rest in bed and by cold applications until sup- 
puration, as is the almost invariable rule, occurs, when the abscess 
should be freely opened, washed out with an antiseptic solution, and 
packed with iodoform gauze to encourage granulation from the bot- 



THE VULVO-VAGINAL GLAND 9±9 

torn. As a rule the incision should be made over the most superficial 
point, which, in most cases, is the internal surface of the labium. 

Kelly prefers, however, to make the incision over the skin surface 
so as to avoid a painful cicatrix which sometimes follows an incision 
made over the mucous surface. 

As a rule, general anaesthesia will not be necessary for the opening 
of these abscesses, but local anaesthesia by chloride of ethyl, cocaine, or 
the application of ice, will be quite sufficient. 

Cysts are best treated by extirpation, after which the opening 
should be immediately closed by interrupted sutures. In case this is 
not possible, after thoroughly laying the cyst open, an attempt should 
be made to obliterate its cavity by cauterization and packing with iodo- 
form gauze. Examination should, at the same time, be made of the 
duct, and, if found diseased, it should also receive attention; otherwise 
it may remain as a source of infection. 

Carcinoma. — One other disease of the vulvo-vaginal glands deserves 
mention, and that is carcinoma. While of rare occurrence, the num- 
ber of cases which have been reported in recent years renders it certain 
that carcinoma may originate in the epithelium of the gland. Clini- 
cally, it appears to develop in middle or advanced life, as a rounded 
tumour of the labium which does not tend to ulcerate. Microscopically, 
the tumour frequently follows the type of adeno-carcinoma. Cases 
have been reported by Geist, Martin, Mackenrodt, Wolf, and Kelly. 

The treatment here, as for malignant disease in other regions of 
the body, is its early recognition and complete removal. 

In Martin's case the patient died of recurrence four years after the 
operation. 



CHAPTER XXII 

THE PELVIC FLOOR AND ITS INJURIES 

The pelvic floor — The "pelvic diaphragm" — Injuries of the pelvic floor — Lacera- 
tions of the perineum — Restorations of the pelvic floor — Immediate operation 
— Instruments — Operations for incomplete lacerations, superficial — Emmet's 
operation, Reed's method of suture; modifications — Operations for complete 
lacerations; Tait's operation; modifications — Repair of deep injuries of the 
pelvic floor — Harris's operation. 



The pelvic floor consists of those structures which by their muscu- 
lar elements are attached to the lowest plane of the pelvic bones and 
which occupy the outlet of the pelvis. These structures considered in 
their entirety include integumentary, aponeurotic, and muscular ele- 
ments, and are penetrated by three canals, namely, the vagina, the ure- 
thra, and the rec- 
tum. The function 
of the pelvic floor 
is to serve as a basis 
of support for the 
superimposed vis- 
cera. This power 
of support is exer- 
cised by virtue of 
the aponeurotic, and, 
particularly, the 
muscular elements 
of the floor; and it 
is to these elements 
that special atten- 
tion is invited. The 
muscles of the pel- 
vic floor are ar- 
ranged in two layers, 
(a) external, and (b) 
internal. The external layer of muscles embraces the bulbo-cavernosus, 
the transversus-perinasi, and the sphincter-ani-externus muscle, with 
fibres from the pubo-coccygeus and the obturator-coccygeus muscles. 
These muscles meet at a central point of convergence, which may 
250 




Fig. 92. — " These muscles meet at a central point of conver- 
gence, which may be designated the nidus perincei. v — 
Eeed (page 251). 



THE PELVIC FLOOR AND ITS INJURIES 



251 




Fig. 93. — " The internal layer, as described by M. L. Harris, 
is composed of four paired muscles." — Reed. 



with propriety be designated the nidus perincei (Fig. 92). The 
perineum proper is a pyramidal structure the base of which lies 
between the fonrchette and the anus, while its apex blends with the 
recto-vaginal septum; its essential structures are derived from, and 
constitute a part of, the external muscular layer of the pelvic floor. 
The internal muscular 
layer of the pelvic 
floor occupies a plane 
about 1.5 centimetre 
above the external 
layer, and, as de- 
scribed by M. L. Har- 
ris (Journal of the 
American Medical As- 
sociation), is composed 
of four paired muscles 
(Fig. 93). 

Harris says that 
" it is not always easy 
in a human subject to 
draw sharp lines of 
demarcation between 
some of these muscles 
at all points, and 

some knowledge of comparative anatomy is necessary to a clear un- 
derstanding of them. Comparative anatomy teaches us that these 
muscles are the representatives of well-developed, clearly defined mus- 
cles, which, in the lower animals are concerned in the movements of 
the caudal appendage, and which, owing to the loss of the caudal appen- 
dage and the assumption of the erect posture through evolution, have 
somewhat readjusted their character and attachments, to conform to 
their new function of closing the pelvic outlet and supporting the pel- 
vic contents. These four muscles are called the ischio-coccygeus, the 
ilio-coccygeus, the pubo-coccygeus and the pubo-rectalis. The ischio- 
coccygeus which arises from the spine of the ischium and is inserted into 
the lateral border of the lower part of the sacrum and the upper part of 
the coccyx; and the ilio-coccygeus, which arises from the iliac portion 
of the obturator fascia and in inserted into the lateral border of the 
lower part of the coccyx, have comparatively little remaining physio- 
logical importance or surgical significance." 

The remaining two muscles, however, are of extreme importance. 
" The pubo-coccygeus arises from the lower border of the symphysis 
ossis pubis, from the posterior surface of the os pubis, and from the 
obturator fascia as far back as the ilio-pectineal eminence. From this 
somewhat extensive origin the fibres pass meso-dorsad, passing by 
the urethra, the vagina, and the rectum, lying cephalad of the lower 
portion of the ilio-coccygeus, and are inserted with those of its fellow 



252 A TEXT-BOOK OF GYNECOLOGY 

from the opposite side by means of a tendinous expansion into the ven- 
tral surface of the coccyx and the lower part of the sacrum, the more 
ventral fibres interlacing directly with those of its fellow as a girdle 
posterior to the rectum. The pubo-rectalis lies beneath, or caudad of, 
the ventral portion of the pubo-coccygeus, from which it is separated 
ventrally by an intermuscular fascia. It arises from, the lower portion 
of the symphysis ossis pubis, or from the beginning of the descending 
ramus and the cephalic surface of the urogenital fascia. Its fibres 
usually form a well-defined muscular loop which passes dorsad, encir- 
cling the rectum at the perineal flexure where it becomes continuous 
with its fellow. In passing by the rectum, some of its fibres enter the 
wall of the rectum, gradually become tendinous, and pass caudad as far 
as the cutaneous surface. A few fibres also pass anterior to the bowel 
between it and the vagina, some of them eventually becoming con- 
tinuous with the transversus-perinsei muscle of the opposite side. The 
pubo-coccygeus and the pubo-rectalis together form what is generally 
termed the levator-ani muscle, and are the most important muscles of 
the pelvic floor. They produce the characteristic perineal flexure of 
the rectum and vagina and form the chief support of the pelvic viscera. 
They must undergo the greatest elongation during the dilatation of the 
pelvic outlet for the passage of the child, and, therefore, are most 
liable to suffer rupture or laceration, as will be shown later. The more 
ventrally placed fibres pass almost directly ventro-dorsad, while on 
frontal section the muscular plane slopes from the periphery toward 
the centre and cephalo-caudad. In the space between the opposite 
muscles ventrally pass the vagina and urethra, and it is extremely im- 
portant to clearly understand the relations of these muscles to the 
lateral wall of the vagina. The normal virgin vagina is not a simple 
straight tube. In passing from without inward the general direction 
of the vagina, for a distance of 1.5 to 2 centimetres within the hymen 
is dorso-cephalad. At this point a distinct change in direction takes 
place and the vagina passes almost directly dorsad. The point of angu- 
lation lies opposite, and corresponds, to the perineal flexure of the 
rectum, and is produced by the pubo-coccygeus and the pubo-rectalis 
muscles encircling these canals at this point and drawing them for- 
ward, or in a ventral direction. With the finger introduced into the 
vagina, one is able easily to recognise the point of angulation, and 
distinctly to feel the edge of the pubo-rectalis muscle through the lat- 
eral wall of the vagina, as it passes in its course toward the symphysis. 

" An incision through the lateral wall of the vagina 1 to 2 centi- 
metres to the inner side of the hymen or its remains will expose the 
median edge of this muscle. It may easily be dissected up almost from 
its origin from the symphysis ossis pubis to the rectum, and in passing 
by the vagina its fibres do not enter or form an attachment directly to 
the vaginal wall. The muscle varies from 3 to 6 millimetres in thick- 
ness and extends in connection with the pubo-coccygeus laterally to the 
wall of the pelvis, the plane in the transverse direction being oblique 



THE PELVIC FLOOR AND ITS INJURIES 253 

to the wall of the vagina. That portion of the vagina lying internal 
to the point of angulation or perineal flexure, and which composes by 
far the major portion of the canal, lies in its ventro-clorsal plane almost 
parallel with the muscular plane, and rests on it, the rectum alone in- 
tervening. Contraction of the muscles of this layer tends to increase 
the perineal flexure of the rectum and vagina by drawing the parts in a 
ventro-cephalic direction, and the opening through the muscular floor 
is thereby maintained ventrad of the line of gravity. The weight of the 
pelvic organs is thus brought to bear on the muscular layer of the pelvic 
floor; that mass of tissue ordinarily called the perineal body lying be- 
tween the rectum and the vagina, and extending from the inner muscu- 
lar floor of the pelvis to the cutaneous surface, has little or nothing to 
do with sustaining the pelvic organs." (Harris, ibid.) 

The pubo-coccygeus and the pubo-rectalis muscles, considered joint- 
ly as the levator-ani muscle, are graphically described by Dickinson 
{American Journal of Obstetrics) as resembling a horseshoe. Without 
reference to accurate anatomical details he says that " it is like a sling 
attached to the pubes in front, its sweep reaching horizontally back- 
ward to encircle the rectum and vagina like a collar. It sustains the re- 
lation of an independent encircling constrictor to the rectum and vagina, 
both of which are drawn by it in the direction of the pubes. It is a 
voluntary muscle with the capacity of lifting from 10 to 27 pounds. In 
cases in which it is inordinately developed it may be a serious barrier 
to the sexual relations while its spasmodic excitation is the frequent 
cause of dyspareunia and vaginismus." 

Meyer designated the internal muscular layer of the pelvic floor as 
the diaphragma pelvis proprium, and there has been a disposition among 
other writers to speak of this layer as the pelvic diaphragm. But this 
nomenclature is both erroneous and misleading. The word diaphragm, 
whether employed in mechanics or biology, conveys the meaning of " a 
partition or septum which separates one cavity from another." The 
most extravagant license can not conjure into existence a cavity below 
the internal muscular layer of the pelvic floor. If the term pelvic dia- 
phragm is to be employed at all, it should be restricted to that parti- 
tionlike arrangement of structures at the utero-vaginal junction which 
divides the recognised cavity of the pelvis from the cavities of the 
vagina, rectum, and, in part, of the bladder. 

Injuries of the pelvic floor may embrace any of the recognised 
varieties of wounds, such as contused, incised, or lacerated. They may 
be restricted to the skin, or they may involve the external muscular 
layer (perineum), or only the deeper muscular layer, or, to a greater or 
less extent, the whole of the structures of the pelvic floor. In this 
chapter we shall confine attention to those injuries which affect (a) the 
external muscular layer (perineum), and (b) the internal muscular layer. 

Lacerations of the Perineum. — Injuries of the external muscular 
layer are chiefly restricted to the perineum and are ordinarily discussed 
under the title of lacerations of the perineum. These injuries rarely 



254 



A TEXT-BOOK OF GYNECOLOGY 



result from external violence, but the traumatism upon which they 
depend is generally an incident of parturition. 

The traumatisms inflicted in this region are generally considered 
and treated as lacerated wounds. Still, there are instances in which 
the injury may be classed both as a contusion and a laceration, and 
upon a proper conception of the true nature of the trauma the treat- 
ment will, in a great measure depend. 

Varieties. — The varieties of these lacerations, or tears, must be con- 
sidered from the standpoint of the direction taken by the tear. This 
will be governed by the presenting part of the child that comes in con- 
tact with the least resistant or most inelastic structure, the force of the 
labour pains, and the anatomic construction at the point of impinge- 
ment. 

It must be remembered that the perineal structure, as a whole, is a 
complex arrangement of muscles, ligaments or tendons, fasciae, and ves- 
sels and nerves, so interwoven and superimposed as to resist a great 
amount of force. One of the functions of the perineum being to close 
the introitus vulvae by the contraction of the sphincter vagina? and 

levator-ani muscles, it is drawn 
or held forward by them, pro- 
ducing an abrupt angle with 
the lower portion of the birth 
canal; so that, in the process 
of descent, the presenting part 
comes into contact with a de- 
cided obstruction, and, should 
it be wanting in elasticity or 
resiliency, the structure is sure 
to be injured. A tear occurs 
at the point of least resistance, 
whether at this point be situ- 
ated a muscle, tendon, or fas- 
cia. This tear will take the 
direction of the course of the 
fibres composing the integral 
part at which the force is 
spent (Fig. 94); for the rea- 
son that it does not require 
so much force to split such a 
structure as it does to sever it 
at right angles. Should a tear 
occur along the course of the 
central tendon it may be de- 
nominated a central tear; if 
along the fibres of the transversus perinaei muscle or the transverse fibres 
of the triangular ligament, a lateral tear, with the prefix " right " or 
" left," as the case may be. The central rupture is regarded by most au- 




Fig. 94. — " This tear will take the direction of the 
course of the fibres composing the integral part 
at which the force is spent." — Dorsett. 



THE PELVIC FLOOR AND ITS INJURIES 255 

thors as far the more frequent, but this is not the experience of Dorsett. 
Out of 1,006 ruptures of the perineum occurring at the St. Louis 
Female Hospital from July 15, 1887, to March 3, 1892, there were 296 
central ruptures, 23? left lateral, 199 right lateral, and 10 ruptures of 
the third degree, or into the rectum, being more or less central. The 
remainder were of a superficial nature, or ruptures of the first degree. 
So great is the tendency for the line of tear to follow the fibres of the 
different tissues forming the perineum, that there are instances in 
which the tear, starting at the raphe, runs along the central tendon, 
here and there breaking a fibre and getting a little farther to one side 
until the sphincter ani is reached and penetrated; which muscle, on 
account of its peculiar circular form, may lead the tear around the anus, 
almost or completely enucleating the lower rectum from the surround- 
ing structures, or it may pass on backward to the fibres of the coccygeal 
ligament and split them till it reaches a point at or near the tip of the 
coccyx. Two cases of enucleation of the lower rectum from these 
severe tears have been observed by Dorsett. 

A laceration may start at the fourchette and take a straight back- 
ward course, following the raphe for a short distance, when, on ac- 
count of a particularly strong fibre or set of fibres of the triangular liga- 
ment or transversus perinsei muscle, it may take a different course, pro- 
ducing a very irregular wound. Lacerations sometimes take a shape 
not unlike the letter L or an inverted Y or T. 

When the head is in the first or second obstetrical position and there 
is not a great disproportion between the child's head and the maternal 
parts, and when the patient is tractable and can be controlled, the 
levator-ani muscle, as a rule, escapes injury. When an occiput posterior 
position is met with, the deeper perineal structures are apt to suffer, 
whether the delivery is instrumental or not. This is due to the fact 
that flexion can not take place and the occiput engages the posterior 
wall of the vagina and ploughs its way through the perineum, tearing 
the levator-ani and other deep muscles on its way outward. Occasion- 
ally, these posterior positions may cause what is known as perforating 
rupture. In other words, the perineum may be perforated by the 
child's head in such a way that the fourchette and sphincter ani may 
remain intact. Such injuries are, however, fortunately rare. 

A most remarkable case of perforating rupture of the perineum is 
related by Liszt (Monatsschrift fur GelurtsliiUfe unci Gynakologie). The 
subject was a primipara, aged twenty years, who had a normal pelvis and 
was in labour thirteen and a half hours. A swelling the size of a goose's 
egg appeared over the perineum and gradually increased in size until it 
ruptured two hours later. The child, which presented by the breech, 
was expelled through the opening, but the head had to be extracted. 
The fourchette and rectum were uninjured. 

For the purpose of description, lacerations of the perineum may be 
described as degrees of injury, according to the extent of solution of 
continuity. As, for example, a laceration through the skin, mucous, 



256 A TEXT-BOOK OF GYNECOLOGY 

submucous, and subcutaneous cellular tissue, and as far as the muscle 
but not into it, may be termed a laceration of the first degree; if through 
the skin, mucous membrane, submucous and subcutaneous cellular 
tissue, and the muscular structures to, or into, the external sphincter- 
ani muscle, a laceration of the second degree; if through all the previ- 
ously mentioned tissues, and also through the anal sphincter into the 
rectum, a laceration of the third degree. 

Prophylaxis. — In the conduct of a case of labour it should be a 
matter of the utmost concern to the obstetrician to guard against a 
rupture of the perineum, the time for the most watchful attention 
being at the close of the second stage of labour; for, when the present- 
ing part is pressing upon the perineum, the tenesmus becomes so great 
that the inclination to strain, as at stool, becomes almost irresistible. 
Still, in many instances, if the patient is directed to " breathe out " 
and to " take short breaths," she may control herself to such a degree 
that the head may, even in a primiparous woman, slip over the peri- 
neum without injuring it beyond a slight tear of the fourchette. Yet 
it must not be forgotten that the maintenance of flexion of the child's 
head is the desideratum, and it is the duty of the obstetrician, by con- 
stant manual effort, so to press the occiput downward toward the hollow 
of the sacrum, that, by the proper amount of moulding of the head, the 
occiput can come well up under the pubic arch. When this stage is 
reached, the force now to be exerted is in exactly the opposite direction 
— that of extension — and is exercised by placing the palm of the right 
hand, not upon the mother's perineum, as was taught by the older 
writers, but upon the part of the child's head that shows in the cleft 
of the vulva, till the parietal eminences are about to escape, when 
the left hand relieves the right, and the index and middle fingers of the 
right hand are carried into the rectum and hooked under the supra- 
orbital arches. Gentle traction is now made with the two fingers of 
the right hand upward toward the pubic arch, while the left hand 
holds the head well against the arch. As soon as there is shown to be 
some progress, the two fingers, already in the rectum, are carried 
farther upward, and the lower border of the superior maxillary bone 
(in the child's mouth) is reached, when traction is made upon it, and 
latterly the child's chin is substituted for the maxilla. During this pro- 
cess of " shelling out the child's head," very effective assistance can be 
rendered by the nurse or assistant, by the insinuation of the fingers 
between the child's occiput and the pubic arch, and by pushing down 
the upper vaginal commissure which engages the back of the child's 
neck, like a collar. This rule should be followed whether the forceps 
is used or not. In the great majority of instances the forceps is only 
necessary to bring down the head into the vulva and is then taken off; 
the remainder of the delivery can be accomplished in the manner indi- 
cated above. In the delivery of all cases, irrespective of presentation or 
position, traction, manual or instrumental, should be in the direction of 
the axes of the birth canal for the preservation of the perineum. This 



THE PELVIC FLOOR AXD ITS INJURIES 257 

rule should be strictly adhered to at the outset. Still, with the utmost 
■care and good judgment, the perineum will be ruptured in a certain 
proportion of cases. J. "W. Bullard (Western lledical Review, Xovem- 
ber 16, 1898), after having consulted Byford, Munde, Martin, Hirst, 
Baldy, Coe, and Montgomery, as to proportion of lacerations during 
Urst labours, has found it to be about 30 per cent. 

Consequences. — The immediate consequences of laceration of the 
perineum are according to the degree of injury sustained. If the lacera- 
tion is of the first degree, the consequences are trivial. If of the second 
or third degree, the normal involution of the vagina and vulva is more or 
less interfered with, and the danger of sepsis greatly augmented. On 
account of the resulting torn and lacerated open wound, pathogenic 
organisms gain ready access. If the laceration extends into the rec- 
tum through the sphincter-ani muscle, the inability to retain the faeces 
.and gas will render the patient a miserable sufferer. 

The remote consequences, when the laceration is of the second or 
third degree, are many and not confined to the site of injury. For it 
must be remembered that the perineum is the support upon which rest 
the internal organs of generation as well as a part of the weight of the 
bladder; so that an impairment of this structure necessarily disqualifies 
these organs from performing their functions in a normal manner. 

TUien the laceration extends to the anal sphincter and is deep 
enough to involve the levator ani, the transverse muscles, and the 
transverse fibres of the triangular ligament as well as the different layers 
of fascia, the anterior wall of the rectum and the posterior wall of the 
bladder are robbed of their natural support, and a sagging of these 
organs is the consequence. As soon as the solution of continuity takes 
place, the divided ends of muscles retract, and, in time, by the pro- 
cess of healing, will be covered by mucous membrane, which does not 
give strength but allows a pouching downward of these organs. Strain- 
ing in the act of defecation or micturition augments the trouble, and, 
in the case of the bladder, a cystocele — in the case of the rectum, a rec- 
tocele — is formed. These abnormal pouches grow progressively larger 
and progressively give more and more trouble. In the case of the blad- 
der, the loss of its posterior support, viz.. the perineum, together with 
the tearing away of its natural moorings from their normal attachment 
around the internal aspect of the pubis by the passage of the child 
through the birth canal, leaves nothing to hold it up. and a sagging of 
the viscus is the result. This sagging down prevents the organ from 
emptying itself completely, and a decomposition of the residual urine 
soon sets up an often intractable cystitis. 

A division of the structures composing the greater portion of the 
perineum, leaving only the sphincter-ani muscle, allows the rectum 
to pouch forward, thus forming the condition known as rectocele. This 
tumour is increased in size by the efforts at defecation, for the reason 
that the anterior wall of the rectum forms almost a right angle to the 
.anus, and, at each attempt to defecate, this angle is increased, and 
18 



258 A TEXT-BOOK OP GYNECOLOGY 

the pouch or sac is consequently likewise increased in size. On account 
of the inability to evacuate thoroughly the contents of the rectum, a 
constipation is inaugurated, which tends still further to increase the 
size of the tumour. 

Not alone to the bladder and rectum, is the mischief done by a 
rupture of the perineum. The vagina, uterus, and uterine adnexa, 
also suffer. The lack of support given the vaginal walls causes them to 
drag the uterus downward, stretching its suspensory structures — viz., 
the broad ligaments on either side, the two utero-sacral ligaments pos- 
teriorly, and the two round ligaments anteriorly. Nature only intended 
these ligaments to act as " guy ropes," to poise the uterus in the pelvic 
cavity, and not as supports. The consequence is a giving way of these 
ligaments, resulting in either descensus or retro-deviations of the 
uterus and adnexa. 

The restoration of the pelvic floor is demanded in all cases when 
the injury is sufficient to cause either destruction or serious deteriora- 
tion of the functional power of this structure. When injuries are 
restricted to the external muscular layer (perineum) the impairment of 
function may consist, either in a mere enlargement of the vaginal out- 
let, with a consequent tendency to rectocele and cystocele, or, if the 
laceration has extended through the recto-vaginal septum, dividing the 
sphincter-ani muscle, the consequent loss of function finds expression 
in faecal incontinence; the indication, therefore, is for the repair of 
what are ordinarily designated the perineal structures. If, on the 
other hand, the injury involves the internal muscular layer of the 
pelvic floor, the resulting impairment of function eventuates, not only 
in a tendency to rectocele and cystocele, but in general ptosis of the pel- 
vic viscera; the manifest indication is, consequently, for a restoration of 
integrity and tone in the impaired deep muscles of the pelvic floor. 
When both layers of the pelvic floor are damaged, as is the case in prob- 
ably the majority of instances, the resulting operation, to be curative, 
must comprehend a restoration of all the injured parts. It is needless 
to say that the necessary prelude to correct treatment must consist in 
careful examination and accurate diagnosis. 

The immediate operation for external injuries of the pelvic floor, 
otherwise called lacerations of the perineum — i. e., the operation for 
restoration of the parts immediately after parturition — is one the expe- 
diency of which must be determined by the character of the laceration 
and the condition of the patient. If the laceration is not associated 
with much contusion, if the line of cleavage is direct and the surface 
smooth and of easy approximation, and if, moreover, the patient's 
condition is such as to admit of the operation, sutures may be applied 
at once and the wound closed. If, however, the laceration is of the 
eccentric variety, if the tissues are bruised and the proximal surfaces 
seem to be infiltrated with blood, and particularly if, in the presence 
of these conditions, the laceration is complete, attempt at imme- 
diate repair may be set down in the vast majority of cases as a mere 



THE PELVIC FLOOR AND ITS INJURIES 



259 



unnecessary and fruitless infliction of pain. The practitioner in justice 
alike to himself and his patient should, before attempting the imme- 
diate repair of these injuries, explain that the majority of such opera- 
tions are failures. Union may be said to occur in less than 50 per cent 
of even favourable cases. When the practitioner deems the case in 




Fig. 95. — Hemostatic 
forceps. — Eobb. 



Fig. 96.— Scalpel. 

— EOBB. 



Fig. 97.— Emmet's left- 
angled, right-curved 
scissors. — Eobb. 



Instruments for 

Catheter, glass 1 

Forceps, hemostatic : 

Long 2 

Intermediate 2 

Small (Fig. 95) 2 

Long dressing 1 

Needles, as for abdominal sections 
(omitting the largest). 

Needle-holders 2 

Needle, Reed's curved 1 

Nozzle, Edebohls's 1 



Perineorrhaphy 

\ Packer, vaginal 1 

I Retractor, small 1 

Intermediate 1 

Scalpels (Fig. 96) 2 

Scissors, right-angled. 1 pair. 



Emmet's left-angled (Fig. 9" 
Straight-pointed 

Sound, uterine 

Tenaculum, straight 

Tenacula, curved 



)-• 



hand a proper one for immediate repair, he should recognise that 
every step of the operation should be done with the strictest antiseptic 
precautions. The patient should be put in position on the table and 
the vagina should be carefully irrigated, preferably with lysol or car- 
bolic-acid solution; if the mercuric bichloride is used the solution should 
not be stronger than 1 to 4,000, because a stronger solution coming into 



260 



A TEXT-BOOK OF GYNECOLOGY 



contact with the raw surfaces of the wound is liable to cause tissue 
changes that will interfere with the union. After cleansing the vagina, 
the upper part of that canal should be carefully packed with sterilized 
gauze, to prevent the escape of the lochia during the progress of the 
operation. After having again cleansed the wound, interrupted sutures 
of sterilized silkworm gut should be inserted, with careful observance of 
the principles governing their application, as set forth in the paragraph 
relating to the elective operation of perineorrhaphy. 

Operations for Incomplete Laceration of the Perineum. — The opera- 
tion for the repair of superficial lacerations of the perineum is very 
simple. A V-shaped area is denuded at the site of the former four- 

chette (Fig. 98), and is 
closed by interrupted su- 
tures (Fig. 99), the re- 
sulting line of approxi- 
mation representing the 
letter Y. 

Emmet's Operation. — 
The patient, after having 
been antiseptically pre- 
pared and anaesthetized, 
is placed upon her back, 
her buttocks at the edge 
of the table, her legs 
thoroughly flexed and in- 
trusted to assistants, or 
preferably, to the me- 
chanical appliances 
which constitute a part 
of the modern operat- 
ing table (Fig. 100), the 
clothing worn during 
operations being omitted 
from the picture in order 
to show better the posi- 
tion of the legs. To 
hold the legs in a flexed 
position is both difficult 
for the assistant and not 
destitute of danger to 
the patient, for injuries 
have happened to the 
hip joint by injudicious 
pressure upon the flexed 
leg. Clover's crutch is not a desirable appliance for the reason that 
its mechanism is calculated to interfere with respiration and to 
become an embarrassment to anaesthesia. As soon as the patient is 






Fig. 98. — " A V-shaped area is denuded at the site of 
the former fourchette." — Eeed. 



TT 



THE PELVIC FLOOR AND ITS INJURIES 



261 



put in this position and the labia are retracted, the posterior wall of 
the vagina will appear as a projecting mass within the vagina (recto- 
cele, Fig. 86). A tenaculum is fixed in the middle and at the apex of 
this mass, which is now 
drawn forward and up- 
ward toward the pubes; 
as this is done the trac- 
tion thereby induced will 
make apparent two folds, 
one on either side, lead- 
ing from the point of the 
tenaculum to each lateral 
sulcus of the vagina. A 
tenaculum is then hooked 
into the caruncle caused 
by muscular retraction 
on either side of the vag- 
inal outlet, and upon the 
tenacula thus placed lat- 
eral traction is made by 
assistants. A gutterlike 
fold is thus formed, the 
external end beginning 
at the caruncle and ex- 
tending upward into the 
lateral sulcus where it 
coalesces with the fold 
from the central point of 
traction maintained by 
the tenaculum drawn up- 
ward toward the pubes, 
and another tenaculum is 
now placed at the site of 
the fourchette, midway 
between the two last 
named. 

The traction made in 
this way indicates the 
area to be denuded, while 
the approximation of the 
two lateral tenacula and 
the final infolding and 




Fig. 99. — " . . . Closed by interrupted sutures, the re- 
sulting line of approximation representing the letter 
Y."— Reed (page 260). 



the one in the vaginal wall will show 
approximation of tissue that is to be 
accomplished by the operation. Again separating these three points, 
and re-establishing the upward and lateral tension, the operator 
can see, in clear outline, the area which is to be denuded. The 
margins of the folds induced by the traction are the indications for 
the incision, which is carried along the crest of one lateral fold to 



262 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 100. — " The patient is placed upon her back, her 
legs thoroughly flexed." — Reed (page 260). 



the bottom of the sulcus on the same side, and from the bottom of 
that sulcus to the central tenaculum, on the posterior vaginal wall; it 
is then carried from this same central point to the bottom of the 
sulcus on the opposite site of the vagina, and along the crest of that 

lateral fold to the vulvar 
margin; the two ends of 
this really continuous in- 
cision are now united by 
carrying an intermediate 
incision from one lateral 
tenaculum directly across 
to the opposite lateral 
tenaculum. The territory 
thus outlined is next de- 
nuded, after which the me- 
dian tenaculum on the pos- 
terior wall of the vagina is 
drawn down to a level with 
the lateral carunculse. Su- 
tures of silver wire are em- 
ployed and are inserted first into one lateral triangle and next into the 
other lateral triangle of the wound. They are passed an eighth of an 
inch back of the margin, and traverse first the mucous membrane and 
then the underlying muscularis; are crossed over to the other margin 
of the same triangle and are passed out from below upward, including 
first the muscularis and then the mucosa. The sutures are inserted 
about one fourth of an inch apart and, in passing from one side to the 
other of the respective triangles, they are made to define a V-shaped 
course, the apex of the letter pointing downward (Fig. 101). This is 
accomplished by inserting the needle and bringing it downward to the 
median line of the triangular space, drawing it out, reinserting it at 
the point of exit, and directing it upward and inward. After the 
sutures have been placed in first one and then the other lateral triangle, 
the "crown suture" is inserted (Fig. 101). This suture is recognised 
by Emmet as the one of principal importance in the entire operation 
and is inserted *at the point of the caruncular depression on one side, 
deeply enough to embrace within its sweep the levator-ani muscle. It is 
brought out on the denuded surfaces, passed over, and is inserted 
through the cellular tissue underlying the tip of the central mucous 
tongue. It is then crossed over to the other side, is inserted deeply 
enough to include within its sweep the levator-ani muscle, and is 
brought out just back of the caruncular depression of that side. A 
second suture an eighth of an inch from the foregoing may be similarly 
inserted if deemed expedient. Interrupted sutures are now passed 
from one side to the other, between the " crown suture " and the 
median perineal tenaculum, at intervals of about one fourth of an 
inch. The sutures are now tied, beginning with those at the apex of 



THE PELVIC FLOOR AND ITS INJURIES 



263 



first one and then the other triangle, the resulting approximated wound 
resembling the letter Y. Care should be taken in tying the sutures; 
for, if tied too tightly, they may induce necrosis from pressure. It may 
be taken as a safe rule that a suture is too tight whenever it blanches 
the tissues that it compresses. 

The foregoing description is intended to convey a conception of 
the technique as employed by Emmet, and as yet practised by him 
and his numerous fol- 
lowers. Many of the lat- 
ter, however, while fol- 
lowing practically every 
other detail of Emmet's 
technique, substitute 
other suture material; 
McMurtry, for instance, 
closes the lateral trian- 
gles with formalinized 
catgut, using silkworm 
gut for the " crown su- 
tures " and for the extra- 
vaginal sutures. From 
the fact, however, that 
formalinized catgut en- 
dures within the tissue 
from fourteen to twenty- 
one days — a longer pe- 
riod than the interrupted 
sutures are ever retained 
— the expediency of in- 
serting buried " crown 
sutures " of this material 
is well worthy of consid- 
eration. 

Feed's method of su- 
turing is as follows: The 
denudation is made in 
the same way as in Em- 
met's operation — but the 
closure is effected en- 
tirely by means of the 

buried formalinized catgut suture. The crown suture is first in- 
serted. A heavy curved needle armed with strong catgut is passed 
from left to right through the cellular layer of the mucous tip; it 
is then inserted a little to the right of the median line and carried 
deep enough to catch in its sweep the levator ani on the patient's 
left side. It is brought out beneath the cutaneous surface, and is 
carried to the opposite side and inserted beneath the cutaneous sur- 




Fig. 101. — " After the sutures have been placed in first 
one and then th& other lateral triangles, the crown 
suture is inserted." — Eeed (page 262). 



264 



A TEXT-BOOK OF GYNECOLOGY 



face, being made to embrace in its sweep the levator ani of the patient's 
right side (Fig. 103), when, being drawn taut, it will show the line& 
of approximation (Fig. 102). If the laceration is very deep and the 
separation is very pronounced, another crown suture of the same ma- 
terial is inserted in the 
same way; the ends of the 
crown suture, or of both 
of them if two are used, 
are left long and, for the 
present, untied. The 
wound is then closed by 
beginning on the inside 
near the apex of the left 
triangle, inserting the 
suture through the deep 
connective tissue and the 
muscularis, and bringing 
it out through the edge of 
the mucosa; it is then 
carried across and in- 
serted through the edge 
of the mucosa, through 
the muscularis, and the 
deep connective tissue. 
The suture is now tied 
and the short distal end 
alone is cut away. This 
gives the suture its an- 
chorage. (See Abdomi- 
nal Section.) After this, 
the needle is made to de- 
fine the same circuit at in- 
tervals of one quarter of 
an inch, or less, until the 
lateral triangle is closed. 
The needle is then carried through the submucous connective tissue to- 
the apex of the other triangle, when, without further preliminary fixa- 
tion, it is made to approximate the margins of the wound as in the pre- 
ceding triangle (Fig. 103). When both lateral triangles have thus been 
closed to the crotch of the Y, this suture is fixed by tying it in the 
deep cellular structures. The crown suture is now tied, the knot being 
on the inner surface of the approximated tissue. The remaining peri- 
neal wound is then closed by an intercutaneous suture (see Abdominal 
Section), forming the stem of the Y. In some cases it is well to fortify 
the approximation with a supplementary serpentine suture, passed sub- 
cutaneously (Fig. 109). The advantages of this method of closure are 
that it insures the best possible approximation of the parts; it gives the 




Fig. 102. — " Being drawn taut it will show the lines of 
approximation." — Reed. 



THE PELVIC FLOOR AND ITS INJURIES 



265 



patient less pain after operation; it is less liable to infection; and there 
is no occasion to remove sutures. 

Various modifications of Emmet's operation have been made, many 
of them, unfortunately, ignoring its sound philosophic principles; 
others, however, while observing the principles of Emmet, differ from 
his operation chiefly in the manner of execution. One of the most 
valuable of these innovations is the procedure of A. Palmer Dudley, the 
essential point of which 
is to take a stitch which 
will draw up all the 
posterior mucous mem- 
brane at the middle of 
the posterior wall, so that 
none of it can interpose 
itself afterward when the 
parts containing the 
tendinous centre of the 
muscular floor of the pel- 
vis are drawn into ap- 
position. This elimi- 
nates the downward-pro- 
jecting tongue of mucous 
membrane left by Em- 
met in his denudation. 
When a rectocele is 
present, the denudation 
is extended upward to 
the crest of the pre- 
senting pouch, forming 
a triangle the apex of 
which is in the medi- 
an line of the posterior 
vaginal wall. The 
wound is closed by a 
series of interrupted cat- 
gut sutures, the ends of 
which are tied externally. 
In passing these sutures 
in cases not complicated 
with rectocele, the nee- 
dle is inserted through 
the cutaneous margin 
and carried back coinci- 

dently with the long axis of the denudation for a distance of, perhaps, 
half an inch; it is then drawn through, reinserted at right angles, and 
brought out at the mucous margin, the buried portion of the suture 
making a letter L; the suture, next carried over to the opposite side at 




Fig. 103. — "The needle is carried through the submu- 
cous connective tissue to the end of the other trian- 
gle when ... it is made to approximate the margins 
of the wound as in the preceding triangle.'" — Reed 
(page 264). 



266 



A TEXT-BOOK OF GYNECOLOGY 



a corresponding point and inserted through the mucous margin at a 
distance of half an inch, is brought out in the midst of the tissue, and 
the needle reinserted at the point of exit and brought out through the 
cutaneous margin, the buried portion of the suture on this side making 
the letter L precisely as did the same suture on the other side. The 
second suture is passed in precisely the same way, the horizontal and 
perpendicular lines being parallel with those of the preceding stitch, 
from which it is distant about one fourth of an inch. Four or more 
such sutures are inserted and the ends are tied externally. In cases in 
which rectocele is present, the sutures are applied beginning at the 
apex of the upper triangle. The needle is inserted through the mucous 
membrane, pointing downward and inward toward the median line, at 
which point it is brought out; reinserted at the point of exit and 
passed through the tissues upward and outward, it is brought out 
through the mucous membrane on the opposite side of the triangle at a 
point directly opposite that of entrance. The buried portion of the 

suture thus intro- 
duced is in the shape 
of a letter V. Other 
sutures are applied in 
the same manner, the 
arms of the V gradu- 
ally widening until, 
in the middle of the 
area of denuded tis- 
sue, the suture is di- 
rectly horizontal, 
while those inserted 
below this point are 
parallel with it. The 
sutures are now tied, 
beginning with the 
upper intra vaginal 
one, the wound when 
closed making a 
straight line along 
the raphe of the peri- 
neum, the fourchette, 
and the median line 
of the posterior vag- 
inal wall. Lawson 
Tait adapted the flap- 
splitting operation to 
incomplete lacera- 
tions of the perineum, but with results less satisfactory than those 
following the Emmet operation, and vastly inferior to those which 
follow the adoption of the flap-splitting principle in cases of complete 




Fig. 104.—" The condition that is presented at examination. 
— Reed (page 267). 



THE PELVIC FLOOK AND ITS INJURIES 



267 



laceration. The Emmet operation may be accepted as a safe work- 
ing method in incomplete tears of the perineum. 

Operations for Complete Lacerations of the Perineum. — When 
the laceration of the perineum is complete, involving the separation 
of the recto-vaginal sep- 
tum and a division of the 
sphincter-ani muscle, the 
resulting condition is 
much more embarrassing 
to the patient and much 
more difficult for the sur- 
geon. In these cases 
there is a much more 
complete retraction of the 
perineal structures, a 
much wider gaping of the 
vaginal orifice, and an 
incontinence of the faeces. 
The condition that is pre- 
sented at examination 
(Fig. 104) is that of a sep- 
tum with only a narrow 
cicatrized margin which, 
if denuded b}^ the ordi- 
nary trimming process, 
would afford but narrow 
surfaces for approxima- 
tion. This, indeed, was a 
cause of failure in the ma- 
jority of the older opera- 
tions. To obviate this dif- 
ficulty and to secure wider 
margin for approxima- 
tion, Lawson Tait hit 

upon the expedient of splitting, rather than trimming, the septum. 
By this means, turning the rectal side of the flap into the rectum, and 
the vaginal side of the septum into the vagina, he secured, without the 
loss of tissue, approximating surfaces varying from half an inch to 
as much more as might be deemed desirable. 

Lawson Tait's Operation. — The technique of the flap-splitting 
operation is as follows: The patient is carefully prepared with due 
antiseptic precautions and with careful attention to the condi- 
tion of the bowels. This latter point is of extreme importance and 
should consume several days in its proper accomplishment. The 
bowels should be relaxed by repeated doses of salines given in small 
quantity and at frequent intervals. The Hunyadi or Apenta water or 
a mild solution of sulphate of magnesium may be given every few hours 




105. — " The three incisions form the letter H. 
Eeed (page 268). 



268 



A TEXT-BOOK OF GYNECOLOGY 



until the bowels are relaxed, after which the saline should be kept up 
at longer intervals for the next couple of days. In the. meantime the 
diet, while abundant, should be chiefly of the liquid variety. Catharsis 
should cease at least twenty-four hours before the operation. On the 
morning of the operation one or two high enemas should be given, 

washing out, not 

~ ' ~ IfJiieiPil only the rectum, but 

the sigmoid and the 
colon. No opiates 
are given to restrain 
the bowels either be- 
fore or after the op- 
eration. The vagina 
is now thoroughly 
sterilized and the pa- 
tient is placed on the 
operating table. A 
bistoury or, prefer- 
ably, a pair of keen- 
edged scissors curved 
on the edge or bent 
at an angle, may be 
employed to divide 
the septum. This is 
done by carrying the 
incision from one 
side, to the other, be- 
tween the vaginal 
and rectal layers of 
the septum, to the 
depth of about half 
an inch. The inci- 
sion is next carried 
out to either side to 
the outer margin of 
the distinctly cica- 
tricial area. Another 
incision is now made, 
beginning a little below, and a trifle to the outside of, the um- 
bilicated point, indicating the location of one end of the retracted 
sphincter-ani muscle. The incision is carried upward along the 
outer margin of the cicatricial area to its upper angle. A similar 
incision is now made on the opposite side. The three incisions 
unite to form the letter H (Fig. 105). It will now be discovered that 
by bringing the two upright lines of the H into approximation with the 
median line there is a restoration of the original contour of the parts. 
In the act of bringing them together, the vaginal flap and the rectal 




Fig 106.— "Other operators pass these sutures through the 
cutaneous margin." — Keed (page 269). 



THE PELVIC FLOOR AND ITS INJURIES 



269 



flap of the septum separate, approximating the broad proximal sur- 
faces. Before the sutures are applied, a little more dissection may- 
be required to expose the buried end of the retracted sphincter-ani 
muscle. This precaution is important. Tait was in the habit of 
closing this operation by passing sutures of silkworm gut by means of 
the Peaslee needle. Although other operators pass these sutures 
through the cutaneous margin (Fig. 106), the principle which he 
always observed in suturing was to apply these interrupted silkworm- 
gut sutures subcutaneously, the object being to draw forward and into 
approximation the retracted subcutaneous structures. The needle was 
inserted into the tissues beneath the jskin, carried under the tissues 
to the opposite side, and brought out just beneath the cutaneous 
margin. Several of these sutures were thus passed and then tied. 
The result was a gaping margin from which protruded the free ends 
of the silkworm gut. 
Superficial sutures 
were next passed be- 
tween the free ends 
of the deep tissue su- 
tures, thus carefully 
approximating the 
external margins of 
the wound. It 
should have been 
stated that it was 
Tait's custom in 
passing the deep tis- 
sue sutures, always 
to make sure that he 
inserted one of them 
in such a position as 
to catch the re- 
tracted ends of the 
sphincter-ani mus- 
cle, which were then 
brought into appo- 
sition when the su- 
tures were tied. The 
sutures were gener- 
erally removed on 
the seventh or eighth 
day, rarely later 
than the tenth. 

Modifications. — The principles of flap-splitting and of sphincter ap- 
proximation first enunciated by Tait have been very generally adopted 
by the profession. These were the essential elements of his teaching. 
Many of his followers have changed the technique of closure by the em- 




Fig. 107. — " The ends of the sphincter-ani muscle are trans- 
fixed by a suture of strong catgut." — Reed (page 270). 



270 



A TEXT-BOOK OF GYNECOLOGY 



ployment of different suture material and by different methods of apply- 
ing the sutures themselves. Eeed during the last ten years has adopted 
the following method of applying the sutures in flap-splitting opera- 
tions. The rectal flap of the septum is caught at its external corners by 

a volsella and approxi- 
mated in the median 
line, its raw surfaces be- 
ing brought together. 
These are now stitched 
together by means of a 
continuous catgut su- 
ture, beginning above 
and extending down to 
the anal margin, a step 
which, for clearness' 
sake, is designedly 
omitted from the illus- 
tration which shows this 
operation in connection 
with a completed opera- 
tion for rectocele. The 
continuous suture is 
now fixed. The vaginal 
flap of the septum is 
next seized and sutured 
in a similar way. The 
previously isolated ends 
of the sphincter - ani 
muscle are transfixed by 
a suture of strong cat- 
gut (Fig. 107) and are 
tied in the median line 
and the suture cut short 
(Fig. 108). A second suture of this kind may be applied if deemed 
expedient. A few rows of continuous catgut suture are now passed 
from side to side, one layer upon another (Fig. 108)y thus carefully 
approximating in an accurate tissue-to-tissue way the 'previously sepa- 
rated structures of the perineum. The operation is concluded by means 
of an ' intercutaneous suture, which may be fortified at the discretion 
of the operator with a buried serpentine suture of the same material 
(Fig. 109). 

There are numerous other operations for the repair of complete 
laceration of the perineum, that have been devised by able surgeons, 
adopted by many operators, and have given satisfactory results. Of 
these the Simon-Hegar operation is one of the most important. It 
consists in denuding the cicatricial area freely, but, instead of leaving 
a central tongue of mucous membrane in the denuded area, a similar 




Fig. 108. — " A few rows of continuous catgut sutures are 
now passed from side to side." — Keed. 



THE PELVIC FLOOR AXD ITS INJURIES 



271 



tongue is removed upward along the dorsum of the vagina. The small 
triangular area thus made in the vaginal mucous membrane is first ap- 
proximated by sutures, after which the remaining bat wings are 
brought together and sutured by their approximated mucous margins. 
The rectal mucous surfaces are then sutured together by means of 
interrupted sutures, the free ends of which are left in the rectum. A 
third row of sutures is finally applied to the cutaneous surface. The 
operations of Freund, Hildebrand, Heppner, A. Martin, and Le Fort, 
all contemplate denudation by cutting away the tissue, and closure by 
the use of interrupted, nonabsorbable, sutures. It is not apparent 
that any of them are more philosophical in conception, more easily 
done, or followed by better results, than is the flap-splitting operation 
of Tait. In conclusion, the practitioner may accept as a safe working 
method, the operation of Lawson Tait for complete laceration of the 
perineum, just as he may 
accept, as already ad- 
vised, the operation of 
Emmet for incomplete 
laceration. 

The repair of deep in- 
juries of the pelvic floor 
has engaged the serious 
consideration of various 
operators. One of the 
principles most emphat- 
ically enunciated by Em- 
met was the necessity of 
reapproximating the 
separated median fibres 
of the levator-ani muscle. 
It would seem, however, 
that in the case of exten- 
sive injuries to this mus- 
cle the technique of the 
Emmet operation will 
not reach or control it, 
and the same may be said 
of those operations to 
which are attached the 
names of Freund and A. 
Martin. Goldspohn was 
the first to devise and 
carry into execution an 

operation calculated to restore the integrity of the deep muscles of the 
pelvic floor (Medicine, July, 1897). In connection with this operation 
he laid it down as an axiom that " direct union of the two lateral halves 
of the muscle and edges of the pelvic fascia beneath the vagina and 




Fig. 109. — " The operation is concluded by means of an 
intercutaneous suture which may be fortified . . . 
with a buried serpentine suture." — Eeed (page 270). 



272 



A TEXT-BOOK OF GYNECOLOGY 



anterior to the rectum, should be the minimum requirement, no matter 
where the rupture showed itself superficially in the vagina." His opera- 
tion consists of an adaptation of the advanced views of Schatz and the 
flap-splitting principle of Tait. It is done by dissecting up the lateral 
walls of the vagina, exposing the injured muscles, and restoring them, 
and the associated fascia?, by buried animal sutures. 

Harris's Operation. — Harris has perfected the technique of this 
operation which he describes {Journal of the American Medical 

Association) as fol- 
lows : " When lacera- 
tion of the perineum 
is present the denu- 
dation of this part is 
made in the usual 
manner. If this 
body be intact, the 
denudation is omit- 
ted. An incision is 
then carried up each 
lateral wall of the 
vagina from 3 to 
5 centimetres. The 
edge of the muscle 
can now usually be 
felt and an incision 
parallel therewith is 
made through the 
perivaginal connec- 
tive tissue, exposing 
the muscle (Fig- 
110), which may 
easily be dissected 
out with the handle 
of a scalpel, blunt 
dissector, or the fin- 
ger, ventrally as far 
as the symphysis, 
and dorsally until it 
curves round poste- 
rior to the rectum. 
Should the muscle 
retracted that its edge ,can 
along the line which the 




Fig. 



110.— " The edge of the muscle can now usually be felt 
and an incision parallel therewith is made." — Reed. 



ends 



have been so ruptured and its ends so 

not be distinctly felt, the incision is made 

muscle should occupy, and careful dissection is made for separated ends. 

The ends of the muscle will be found connected by cicatricial tissue. I 

have yet failed to find the remains of the muscle even when badly torn 

and the ends widely separated. 



m 



THE PELVIC FLOOR AND ITS INJURIES 273 

" The muscle may vary considerably in thickness, and, when very 
thin and ribbonlike, it may be torn by a careless dissection. When 
multiple small lacerations are present, the muscle will not be entirely 
separated at any point, but will be lengthened, loose, and relaxed. In 
width or distance laterally, the muscle may be dissected from 3 to 5 
centimetres. When it has been well freed, forceps should be placed 
on either side of the portion to be resected, so that the ends when cut 
shall not retract out of reach. The portion resected should correspond 
to the point of laceration if found, or when no distinct separation is 
found, to about the centre of the muscle. The extent of the piece 
resected will depend upon the amount of separation or the degree of 
lengthening and relaxation. It should be sufficient so that when the 
ends are drawn together the floor of the pelvis will be restored to its 
normal position and degree of tension. The ends of the muscle are 
then sutured together with an interrupted or continuous catgut stitch, 
which, of course, remains buried. The opposite side is treated in a 
similar manner when the incision of the lateral walls of the vagina 
is closed by a catgut suture. This latter suturing should be thoroughly 
done so that no openings will remain through which fluids or infection 
may reach the deeper parts. When the perineum has been torn this 
is closed in the usual way." 

Hemorrhage in the course of this operation is sometimes free, never 
excessive and always controllable. It is, however, of extreme importance 
that all bleeding points be secured before the operation wound is closed, 
as a hematoma will prevent union by first intention, and, by a favouring 
infection, may defeat the objects of the operation. 

The operation in the hands of Harris has proved entirely satisfac- 
tory. By its means he restores the normal floor of the pelvis in regard 
to both tone and integrity, carries the vaginal opening ventrad to its 
normal position, and restores its perineal flexure, while the muscles 
regain and retain their contractility and resume their elevating and 
sphincteric action at the vaginal orifice. 



19 



CHAPTEE XXIII 

MALFORMATIONS OF THE UTERUS 

Classification : Embryonic, total, postnatal — Absence — Uterus unicornis — Fcetal r 
infantile or pubescent — Uterus septus — Uterus bicornis — Uterus duplex — Minor 
malformations; atresia — Treatment; stomatoplasty. 

The malformations of the uterus are very numerous and they are 
among the best known of all the structural anomalies to which the 
organs of the body are liable. Further, their mode of origin is in 
most instances fairly well understood, a fact largely explicable by our 
considerable knowledge of the embryology of the utero-vaginal canal. 
They have also a marked and practical bearing upon the phenomena of 
the reproductive life of the woman, gynecological no less than obstet- 
rical. 

Classification. — The most recent and most approved classification 
of the malformations of the uterus is founded directly upon the de- 
velopment of the organ (F. von Winckel, Eintheilung der Bildungshem- 
mungen der weiblichen Sexualorgane, 1899). Uterine development 
may be divided into two periods, an antenatal and a postnatal; the 
former may again be subdivided into an enibryonic and a foetal period. 
The embryonic development of the organ takes place, roughly speaking, 
in the first three months of intrauterine life: it passes through three 
stages, in the first of which there exist the two Mullerian ducts as 
solid cords in the neighbourhood of the Wolffian ducts (first month); 
in the second, the ducts obtain their lumen and unite externally 
into one utero-vaginal tube (second month); and in the third, the 
ducts fuse internally into one hollow tube, the utero-vaginal canal, 
their upper parts, however, remaining distinct as the Fallopian tubes 
(third and fourth months). The foetal development of the uterus oc- 
curs during the remaining five or six months of intrauterine life, and 
chiefly consists in the formation of the fundus of the organ, the 
transition from the uterus planifundalis into the uterus foras arcuatus, 
or foetal uterus. Postnatal development takes place in two stages: 
in the first, corresponding to the first ten years of extra-uterine 
life, through the greater growth of the body as compared with that 
of the cervix, the uterus foetalis becomes the uterus infantilis', 
and in the second, which may be said to extend from the tenth to 
the sixteenth year, the infantile uterus takes on the characters of 
274 



MALFORMATIONS OF THE UTERUS 



275 



the adult but virgin organ. Now, the majority of uterine malforma- 
tions are simply stages of development normally temporary but which 
have become permanent, and they may be divided into groups corre- 
sponding to the developmental stages which have been enumerated. 
These groups may be put in the form of a table. 



Embryonic 



Periods of life. Groups. 

I. (a) Absence of uterus, complete, together with absence of 

tubes and vagina (very rare). 

(b) One-horned uterus, with no trace of the other horn 

{uterus unicornis sine ullo rudimento cornu alterius). 

II. (a) Externally double uterus (uterus duplex sine didelphys ; 

uterus bicornis). 

(b) Solid or partly excavated uterus (uterus solidus, uterus 
rudimentarius, uterus par tim excavatus). 

(c) Combination of («) and (b) (uterus duplex solidus. uterus 
bicornis rudimentarius). 

(d) One-horned uterus, with other horn solid or partly exca- 
vated (uterus unicornis cum rudimento cornu alterius). 

III. Uterus divided internally more or less completely, without 
or with external signs of duplicity (uterus septus, 
subseptus, uterus bicornis septus), 
f IV. Uterus with flat fundus, with or without complete or par- 
tial internal duplicity (uterus planifiuidalis septus, 
subseptus, simplex). 
V. Uterus with foetal characters (small body, large cervix). 
Postnatal VI. Uterus with infantile characters (uterus infantilis). 



Foetal 



There are some malformations which do not find a place in this 
scheme of classification. One of them, the trifid uterus or uterus 
accessorius, is specially difficult of embryonic explanation. To account 
for it we have to suppose the existence of a double Miillerian duct 
on one side; possibly it arises in the pre-embryonic or germinal period. 
Congenital prolapsus uteri also, which may be grouped with the mal- 
formations, does not represent a stage in the development of the 
organ so far as is known; since, however, it has always been found 
associated with spina bifida, it may be really rather a concomitant 
anomaly of spinal arrested development than an arrest in the evolu- 
tion of the uterus. As to the cause of these arrests in uterine de- 
velopment there is still much darkness: inflammatory processes, e. g., 
foetal peritonitis; defective formation of the abdominal walls, e. g., 
umbilical hernia: the presence of tumour germs preventing union of 
the Miillerian ducts, and traction upon these ducts exercised by neigh- 
bouring structures, have all been adduced as possible teratogenic fac- 
tors; but they are all insufficient to explain the anomalies which have 
arisen in the emb^onic period of intrauterine life. It will probably be 
found that uterine malformations, like malformations and monstrosities 
of other parts of the body, are due to the action of germs, toxines, and 
poisons, upon the tissues in the course of evolution (Pathology of the 



276 A TEXT-BOOK OF GYNECOLOGY 

Embryo.) (Scottish Medical and Surgical Journal, v, 481, 1899). It is 
unnecessary in a work such as this to describe in detail all the varieties 
and subvarieties of uterine malformation which the pathologist has 
differentiated; it will be sufficient if the leading types are dealt with 
in outline. 

Absence or Rudimentary State of the Uterus. — Complete absence of 
the uterus, save in sympodial foetuses and the acardiac twin monstros- 
ity, is of excessive rarity; indeed, it is doubtful whether its occurrence 
in the adult woman has been established. On the other hand, it is 
far from uncommon to meet with patients in whom the organ is 
physiologically absent, or, to put it in other words, in whom there is a 
rudimentary uterus (solidus, partim excavatus, membranaceus). The 
tubes and vagina are usually also defective in such cases, but it is 
common to find a well-formed vulva and even a short vestibular vagina 
which has been made deeper by attempts at coitus. The symptoms 
vary with the presence or absence (or at least physiological absence) 
of the ovaries. There is always necessarily amenorrhcea; but when 
there are functionating ovaries menstrual molimina are met with, there 
are occasionally vicarious hemorrhages, and there may be a great deal 
of pelvic pain. Secondary sexual characters are generally present, but 
the vulvar hair may be defective. By means of a recto-abdominal 
bimanual examination (under an anaesthetic if necessary), and with 
the help of a sound in the bladder, it can usually be made out that 
the uterus is seriously defective. In the marked cases no thickness of 
tissue can be felt between the rectum behind and the bladder in front. 
It is doubtful in these instances whether any treatment of the nature 
of ferruginous tonics and the like should be adopted, for such will 
only prove ineffective and disappointing to the patient. When severe 
monthly suffering exists, the opening of th,e abdomen and the removal 
of the functionating ovaries must be considered; indeed, it is demanded 
in many instances, and can be done with not more than the ordinary 
risks of a coeliotomy. Vineberg {Transactions of the American Gyneco- 
logical Society, xxiii, 396, 1898) has recently reported a case of this 
kind in which the removal of the ovaries was followed by the disappear- 
ance of symptoms; during the laparotomy it was noted that in addition 
to the ovaries there were two small oval bodies lying at the pelvic brim 
which were probably rudimentary uterine cornua. 

Uterus Unicornis. — The absence of rudimentary development of 
one horn of the uterus produces the unicornate variety; when there 
is a rudimentary horn it may either be solid or show a cavity, and 
under the latter circumstances pregnancy or menstrual retention may 
occur in that cavity. The one-horned uterus has no proper fundus, 
for it inclines to one side and tapers to a point where it becomes con- 
tinuous with the Fallopian tube (only one tube is usually present). 
Concomitant malformations are: small vagina, vagina septa, absence 
of one kidney and ureter, rudimentary condition of the ovaries. The 
uterus unicornis is not often diagnosticated during life unless it is dis- 



*^i 



MALFORMATIONS OF THE UTERUS 277 

covered during a laparotomy. Menstruation is not necessarily affected 
and pregnancy may occur in the single well-developed horn and pass 
to a normal termination; but when there is gestation in the rudi- 
mentary horn, then rupture of the sac commonly happens with results 
practically undistinguishable from those found after the bursting of 
a tubal pregnancy. 

Foetal and Infantile or Pubescent Uterus. — When the uterus in the 
adult woman instead of taking on its full development retains its 
foetal or infantile characters, it is common to find along with it a 
poor mammary and vaginal development with symptoms of defective 
ovarian formation and sometimes such systemic disorders as chlorosis. 
There is either amenorrhcea or a scanty flow; sterility is met with; and 
there may be also dysmenorrhea. The vaginal and bimanual exami- 
nations, together with the introduction of the sound, should enable 
a diagnosis to be formulated, and the relation of the size of the body 
of the organ to that of the cervix will distinguish the foetal from the 
infantile type. The treatment will be directed toward establishing the 
growth of the uterus, and this is far from hopeless in the infantile form. 
Marriage has sometimes a good effect but should not be recommended 
unless the menstrual function has been established. In the unmarried, 
reliance must be placed upon the administration of iron, arsenic, and 
quinine, together with nourishing food and gymnastic exercises; in the 
married, electrical stimulation of the uterus or simply the periodical 
passing of the sound may be employed, but the insertion of a stem 
pessary as recommended by many is not free from risk and is of 
doubtful efficacy. 

Uterus Septus. — The least marked form of double uterus is the 
septate variety in which the only indication of duplicity is found in 
the division of the interior more or less completely into two cavities 
{uterus septus, subseptus). Externally the uterus appears to be single 
but has sometimes a more markedly globular outline than is usual. 
The two cavities are commonly situated laterally, and there may or 
may not be indications of duplicity in the cervix. The clinical symp- 
toms are indefinite: there may be amenorrhcea and dysmenorrhcea : or 
there may occur the curious twice monthly recurring hemorrhage which 
may be supposed to be menstruation from the two cavities of a non- 
synchronous type: and if one of these discharges is small in amount 
and accompanied by pain we have an explanation of one variety of the 
midpain or " Miti 'elsch men. " It is possible that a septate uterus may 
be a cause of habitual abortion, at any rate in one case the division 
of the uterine septum was followed by a normal pregnancy. During 
curettage the curette has been known to pass from one cavity of a 
septate uterus into the other, giving the sensation of perforation of 
the organ (Blondel. Bulletins et memoires de la Societe obstetricjue et gyne- 
cologicjue de Paris, p. 53, 1898). The presence of the septum may 
complicate labour in this form of malformation; it may cause a mal- 
presentation or a low implantation of the placenta, or to it the pla- 



278 A TEXT-BOOK OF GYNECOLOGY 

eenta may be attached, in which case hemorrhage in the third stage 
is to be looked for. The diagnosis of this malformation has usually 
been made accidentally during the extraction of the placenta or in 
turning. 

Uterus Bicornis. — In the bicornate uterus the upper part of the 
body shows distinct duplicity but the lower part and the cervix are 
single; on internal examination it may be found that the duplicity 
extends to the cervical canal also. The degree of separation of the 
two horns varies within wide limits, from a simple notch on the 
fundus to a wide interval. Further, the horns may be of the same or 
of different size, and in the interval between them may be seen a band 
stretching from rectum to bladder (recto-vesical ligament). The ex- 
ternal genitals are generally normal but the vagina may show different 
degrees of duplicity (vagina septa, subsepta). One of the horns may be 
solid or partly imperforate, and in the latter case it may become the 
seat of a pregnancy or a menstrual blood accumulation (hematometra). 
The clinical history will be very similar to that met with in the septate 
variety. As regards menstruation, there may be a simultaneous dis- 
charge from both cavities each month, or a flow from one cavity one 
month and from the other the following month, or a discharge from 
each cavity each month but not at the same time (fortnightly variety). 
Pregnancy, apparently, not uncommonly happens in the bicornate 
uterus: during it, hemorrhage may go on from the unoccupied horn or a 
decidual membrane may form in it; both horns may contain impreg- 
nated ova, and the age of the gestation may not be the same in 
each, thus explaining some of the anomalous cases of superfcetation; 
and, rarely, a twin conception may occur in one horn. Labour may 
be interfered with in various ways: there may be a malpresentation; 
there may be delay from the presence of the recto-vesical band; there 
may be a low implantation of the afterbirth; and, as Halban (Archiv 
fur Gynakologie, lix, 188, 1899) has lately shown, in cases where the 
pregnant horn lies obliquely to the empty one the head of the infant 
may be driven during labour through the septum between the two 
cavities, and what was a left-sided foetus may be expelled through the 
right cervical orifice. The diagnosis of the uterus bicornis, like that 
of the septate organ, is often not made till labour supervenes or 
till the abdomen is opened for some purpose; but if a double vagina 
or a double os uteri exists the anomaly may be suspected, and then 
a careful examination bimanually and with two uterine sounds may 
suffice to make it plain. 

Uterus Duplex. — The most complete form of double uterus is the 
uterus duplex, separatus or didelphys; in it, the Miillerian ducts have 
failed to unite in that part of them which goes to form the body and 
cervix of the uterus, and commonly also in the vaginal part, so that 
there is at the same time a vagina septa. It is much rarer than the 
uterus bicornis and it is impossible to distinguish the one from the 
other with certainty during life. In a case reported by Ameiss 



MALFORMATIONS OF THE UTERUS 



279 




Fig. 111. 



-" A bicornate uterus with each horn well 
developed." — Keed (page 281). 



(American Journal of Ob- 
stetrics, xxxiii, 693, 1896) 
both uteri were some- 
what retro verted; and in 
one put on record by 
Bernhard (Centralblatt 
-fur Gynakologie,xxi,14:64:, 
1897) both were fcetal in 
development; in Ameiss's 
case there was pregnancy 
and in Bernhardt ster- 
ility. 

Minor Malformations. 
— The uterus, in addi- 
tion to the typical and 
marked malformations which have been already described, may be the 
subject of smaller anomalies, such as the want of rounding of the fundus 
(uterus planifundalis), imperf oration of the cervical canal, or the 

presence of a diaphragm 
in it. Congenital pro- 
lapsus uteri has been re- 
corded (Ballantyne and 
Thomson, American 
Journal of Obstetrics, 
xxxv, 161, 1897); curi- 
ously enough in all the 
reported instances it 
has been met with in 
infants suffering from 
lumbo - sacral spina bi- 
fida. In one sense 
pathologic anteflexion 
and retroflexion of 
the uterus may be re- 
garded as malforma- 
tions; but they are con- 
sidered elsewhere. Con- 
genital elongation of the 
cervix or conical cervix 
also occurs. 

Atresia, or complete 
occlusion of the cervical 
canal, resulting in reten- 
tion of the menstrual 

Ekk 112.-" This secretion . . . often accumulates to a fluid > is sometimes en- 
degree that results in dilatation of the cervical canal." countered. Among the 

—Eeed (page 282). minor malformations of 




280 



A TEXT-BOOK OF GYNECOLOGY 




the uterus may be mentioned stenosis, by which is meant a narrowing 
of the calibre of the canal, the constriction being situated as a rule 
either at the external os or the internal os, or, it may include the 
entire canal. 

The treatment of malformations of the uterus must, of course, vary 
according to the condition. In those cases in which the uterus is 
absent or extremely rudimentary, but in which there develops a men- 
strual molimen, the patient may be seriously afflicted with ineffectual 
efforts at menstruation. Profound neurotic disturbances are liable to 
ensue. In these cases the only relief lies in extirpation of the rudi- 
mentary ovaries. In those cases in which the uterus is foetal, infantile, 
or pubescent, the degree of development encoun- 
tered will determine the remedial course to be 
employed. If the uterus is less than an inch and 
three quarters in longitudinal diameter, any effort 
to force its development by local means will prob- 
ably prove unavailing; or, if development is pro- 
voked, there is but little hope that it can be car- 
ried beyond that degree which will result only in 
the most unsatisfactory establishment of the men- 
strual function. If, however, the uterus is an 
inch and three quarters or more in depth, intra- 
uterine faradization may be employed with some 
prospect of success. Massage of the uterus is like- 
wise an expedient calculated to promote its 
growth. But little, however, is to be promised in 
these cases. Patients or their friends may be 
assured that in certain instances the uterus has 
suddenly developed after having remained more 
or less rudimentary for years. These may be 
called instances of delayed development. A nor- 
mal exercise of the menstrual function is never 
to be promised in these cases, nor is pregnancy to- 
be held up as either possible or desirable. It is 
frequently to be noticed that girls with pubescent 
uteri and corresponding deficiency of the menstrual function show 
a tendency to obesity. These phenomena can only be accepted 
as exemplifications of the biologic law of antagonism between growth 
and genesis. The indication for treatment in these cases is to 
reduce the flesh and improve the quality of the blood which will 
generally be found to be deteriorated in some particular. When 
the flesh is reduced to the normal standard and the normal bal- 
ance of the nutrient functions is thereby properly established, 
the uterus sometimes shows a disposition to develop without local 
treatment. The latter, however, is important and should not be 
omitted. The bicornate or septate uterus may be capable of exer- 
cising a menstrual function in either of its compartments. In occa- 



Fig. 113.— "It is often 
necessary to remove 
a segment of tissue 
from either the an- 
terior or posterior lip 
of the cervix." — ■ 
Eeed (page 283). 



MALFORMATIONS OF THE UTERUS 



281 



sional instances one cavity, and still more rarely both, is closed, with 
resulting hematometra. The condition may be undetected for some 
time, for the reason that the menstrual discharge may regularly appear 
from one side of the uterus, while it is retained in the other side. The 
latter condition, however, sooner or later develops pain which calls for 
intervention, when the real condition of the uterus is for the first time 
discovered. The appearance presented in the examination is some- 
times bewildering in view of the fact that the gradual accumulation of 
fluid may have forced a comparatively thin and elastic septum down- 
ward through the exter- 
nal os, whence it pro- 
trudes in the form of a 
cyst. In these cases a 
mere excision of the wall 
will result in the collapse 
of the cystlike accumula- 
tion. Cullingworth has 
reported (Transactions 
of the American Gyneco- 
logical Society) an inter- 
esting case which pre- 
sented all the symptoms 
of a suppurating cyst 
outside the uterine cav- 
ity, with a fistulous com- 
munication between it 
and some part of the 
uterine canal. Explora- 
tion by abdominal inci- 
sion revealed a bicornate 
uterus with each horn 
well developed, the right 
being larger, more 
globular in shape, and 
situated farther back in 
the pelvis, than the left. 
The two horns con- 
verged toward an isth- 
mus and were continued in a common cervix. A retroperitoneal mass 
on the right of the cervix was found to be the origin of the discharge 
and was removed by vaginal section. It proved to be the expanded 
right half of the cervix (Fig. 111). 

Stenosis may be relieved by an operation which Delageniere (Chi- 
rurgie de Vuterus) appropriately designates as stomatoplasty, which has 
for its object the permanent dilatation of the cervical orifice. Various 
expedients have been devised for this purpose. Courty before 1880 
and Kuster in 1885 promulgated the idea of discission of the neck 




Fig. 114. — " Cases where there has been long distention 
with menstrual fluid." — Reed (page 283). 



282 



A TEXT-BOOK OF GYNECOLOGY 



with reference to a permanent enlargement of the external os. Dela- 
geniere (Chirurgie de V uterus, p. 328) has investigated the literature 
of the subject, and finds that the examples of Courty and Kiister have 
been followed by Dudley, Nourse, Beed, and Pozzi; although the 
object aimed at by these different operators has been somewhat differ- 
ent. The procedure of Kiister, like that of Dudley, was designed 
simply to enlarge the otherwise straight uterine canal which terminated 
in a contracted os; while the operations of Dudley and Eeed were 

designed more especially 
to straighten the tortuous 
canal in cases of ante- 
flexion. 

Enlargement of the 
external os is indicated in 
all cases of either occlu- 
sion or narrowing of that 
orifice. The same may be 
said of those cases of con- 
genital atresia that are oc- 
casionally noted. In both 
cases the cause may arise 
from narrowing, either 
congenital, or due to a 
cicatricial deposit follow- 
ing the application of 
strong caustics or the ex- 
cessive narrowing of the 
canal by trachelorrhaphy. 
One of the first of 
these sequent conditions 
is the retention of the 
normal cervical secretion. 
This secretion, albumin- 
ous in character, often 
accumulates to a degree 
that results in dilatation 
of the cervical canal (Fig. 
112). In this state the re- 
tained secretion forms a 
mucous plug which entirely occludes the lower end of the uterine tract. 
Such a condition persisting through months or even years results sooner 
or later in hypertrophy of that organ; not only is the uterus enlarged, 
but hypertrophic endometritis is developed. Dysmenorrhcea of the 
obstructive variety is an ordinary result. The endometrial changes 
may go to the point of fungous degeneration in which case menorrhagia 
and metrorrhagia are the consequences. In the absence of the fore- 
going indications, or, for that matter, in cases in which they are pres- 




Fig. 115. — "There exists a redundant endometrium 
which may demand subsequent curettement." — 
Eeed (page 283). 



M 



MALFORMATIONS OF THE UTERUS 283 

ent, sterility is the condition which brings the patient to the doctor's 
office. The obstruction to conception which is afforded, mechanically, 
not only by the narrowed orifice of the uterus, but by the constant plug 
of mucus within the cervical canal, are the conditions that demand 
removal. 

The operation may be performed by different methods. In cases in 
which the os is of the pin-hole variety, very narrow and with a very 
considerable amount of retained cervical secretion above it, the cervical 
margins will be found to be little else than a film of tissue which is 
easily broken down by a dilator, or may be successfully broken up by 
means of a stellate incision. This is sometimes all the operation that 
is necessary; in the majority of cases, however, it will not be found to 
be sufficient. It is often necessary to remove a segment of tissue from 
either the anterior or posterior lip of the cervix (Fig. 113) and to bring 
the mucous membrane out, stitching its margin fast to the denuded 
margin of the other lip of the incision. If this is done anteriorly 
and posteriorly, a slight bilateral incision having been previously made, 
a very slight ectropion is produced. The results of the operation are 
very generally satisfactory. It should be remembered, however, that 
in cases where there has been long distention with menstrual fluid 
(Fig. 114) there exists a redundant endometrium (Fig. 115) which may 
demand subsequent curettement. 

Congenital elongation of the cervix or conical cervix may be treated 
by forcible dilatation; if this is not satisfactory the cervix should be 
amputated. (See Amputation of Cervix.) 



CHAPTER XXIV 
DISPLACEMENTS OF THE UTERUS 

Normal position of the uterus — Displacements in general : Varieties, causes, pathol- 
ogy, treatment — Retro-deviations : Symptoms and diagnosis — Treatment : 
Massage, electrolysis, tamponade, pessaries, surgical — Shortening the round 
ligaments — Alexander's operation — Mann's operation — Goffe's operation — By- 
ford's operation — Vaginal fixation: The fundus, the cervix — Pryor's opera- 
tion — Ventral fixation — direct, indirect — Anterior abdominal cuneo-hysterec- 
tomy — Ante-deviations : Symptoms, pathology, treatment — Dilatation and 
curetting — Dudley's operation — Prolapsus: Etiology, pathology, symptoms — 
Treatment: Conservative, surgical — Emmet's operation (anterior colporrhaphy) 
— Inversion: Symptoms, prognosis, pathology, treatment. 

The normal position of the uterus can not be indicated by definite 
lines or specific limitations. By the nature of its construction and in 
consequence of its visceral relations, it has a considerable range of 
mobility. In infantile life its long axis presents but slight deviation 
from the long axis of the body, while its locus is on a line with the 
pelvic inlet. In mature life, however, the fundus leans forward to 
such a degree that the long axis of the uterus lies at right angles with 
the brim of the pelvis, the change of position amounting to about 45°. 
There occurs at this time a normal recession of the organ, until its 
fundus lies a little below a line drawn from the top of the symphysis 
pubis to the promontory of the sacrum. The distance from this line 
to the coccyx is about five inches, one half of which distance is occu- 
pied by the uterus in its long axis. While this definition of the posi- 
tion of the uterus is as nearly correct as can well be stated in words, 
the fact should be remembered that this organ vacillates both in actual 
location and relative position. A loaded rectum or sigmoid may force 
it forward, while, in the presence of an empty bowel and a distended 
bladder, the fundus of the uterus is lifted upward and backward. The 
uterus being swung in the pelvis by attachments upon either side, the 
focal points of which are situated laterally in the middle segment, it 
follows that when the fundus is moved in one direction, the cervix 
must move in the opposite direction. Aside from these movements 
the uterus has to a certain extent an up-and-down movement, rhyth- 
mical with the respiratory movements of the abdominothoracic dia- 
phragm. It is this movement of the uterus, observable in almost any 
patient upon the examination table, that renders it more appropriate 
to designate as the pelvic diaphragm the structures in which the uterus 
284 



DISPLACEMENTS OF THE UTERUS 285 

is embedded, rather than to apply that term to the deep muscular layer 
of the pelvic floor. These movements are normal, and any change of 
position within this normal range of activity should not be construed 
as a departure from the healthy standard. The arc of mobility may 
vary from 45° to 90°, while, with the rectum and bladder empty and 
with no undue voluntary pressure from above, the uterus will be found 
to return to a position approximating that already defined. A uterus 
may be said to be displaced when it ceases to manifest these normal 
variations of position, and when it persistently remains in a position 
distinctly at variance with the one which it should occupy under 
average conditions. 

A proper comprehension of uterine displacements presupposes an 
understanding of the anatomic connections and physical forces by which 
the womb is retained in position in a state of health. It is important, 
at the outset, to look upon the uterus as a suspended rather than as a 
supported organ. The suspensory apparatus consists of (a) the peri- 
toneal duplication called the broad ligaments, (b) the round ligaments, 
(c) the utero-sacral ligaments, (d) its attachments to the bladder and 
(e) to the structure comprising the floor of the cul-de-sac of Douglas, 
while (/) the cellular tissue at either side of the uterus is not to be 
ignored. The idea that the uterus is supported by a column from be- 
low was long ago demonstrated as fallacious by Emmet. A moment's 
reflection upon the intrauterine structures will convince the reader 
that they are neither constituted nor arranged to furnish support to 
the uterus; on the contrary, so far as they tend to exercise a modifying 
influence upon that organ at all it is to draw it farther down in the 
pelvis, rather than to maintain it at its normal level. It is to be 
recognised, however, that the vagina, the lower segment of the rectum, 
and the lower third of the bladder, are kept from exercising undue and 
overpowering traction upon the uterus and its suspensory apparatus 
by virtue of the supporting influence of the pelvic floor when in a 
state of integrity. 

The varieties of uterine displacement may, in fact, be as numerous 
as are the variations from its average normal position. For con- 
venience of study, however, these deviations are classified with refer- 
ence to the abnormal movement of the fundus anteriorly, posteriorly, 
or laterally, and with reference to the movement of the entire organ 
either upward or downward. As a result, we shall have occasion to 
consider in the order of their frequency and relative importance (a) 
retro-deviations, (b) ante-deviations, (c) prolapsus, (d) lateral deviations, 
and (e) inversion. The ante- and the retro-deviations are further divided 
into versions and flexions. A uterus is said to be in a condition of ver- 
sion when its longitudinal axis deviates from its normal plane; while 
flexion of the uterus consists in the bending of the organ upon itself. 

The causes of uterine displacements are numerous, and are to be 
considered in their relation to abnormal deviations in general, rather 
than with reference to the operation of a particular cause in producing 



286 A TEXT-BOOK OF GYNECOLOGY 

a particular displacement. Thus, constipation, by inducing pressure 
upon the uterus through the direct influence of either a loaded rectum 
or sigmoid, or by the pressure of the enteroptosis that constipation 
sometimes causes, forces the uterus downward in the pelvis. Whether 
the pressure thus exercised exaggerates the pre-existing normal ante- 
version, or whether it forces the uterus backward into a distinct retro- 
deviation, depends upon the incidence of co-operative forces. This is 
illustrated by the downward pressure exercised as above indicated at 
the same time that the uterus is forced backward by a distended blad- 
der, a combination of influences calculated to produce retro-deviation; 
or the same condition may be induced by having the uterus lifted up 
by means of a distended bladder when the patient receives a sudden 
fall or jumps from a vehicle, landing upon her heels, thus forcing the 
fundus suddenly below the promontory and into the excavation of the 
pelvis. Child-bearing is, perhaps, the most fruitful single cause of 
uterine displacements. In the parturient act, the uterus is subjected 
to violent influences which may damage its suspensory apparatus. If 
the lying-in woman gets up before the womb has had time to shrink, 
or if she engages in laborious occupation while it is yet heavy, she is 
very liable to have some form of uterine displacement as a result. In 
many cases, even after the lapse of considerable time, a remaining sub- 
involution makes the uterus so heavy that it is thereby forced out of 
its normal poise. Occupation, particularly those employments ■ that 
involve the lifting or carrying of heavy burdens, or that necessitate 
overhead work or much stair-climbing (see General Etiology), tend to 
force the womb out of position. Malpositions of the uterus are very 
common among young women employed in shops and factories, where 
long hours of standing are necessary. Pelvic inflammations, particu- 
larly cases of metritis of puerperal origin, and of Fallopian tube in- 
fection, resulting in pelvic exudations and consequent adhesions, are a 
fruitful source of displacements. 

The pathology of uterine displacements has been foreshadowed to 
a certain extent in the etiology. The changes that ensue on the first 
departure of a permanent character from the normal poise of the uterus 
are various; thus, in the case of a retro-deviation the fundus drops 
backward into the cul-de-sac, in a position of either version or flexion. 
In either of them, in the presence of more or less acute inflammation 
of the pelvic peritoneum, adhesion is likely to occur. The altered 
position of the uterus with the consequent interference with the circu- 
lation, particularly on the venous side, results in a mechanical engorge- 
ment of the organ. The turgescence results in enlargement, increased 
weight with more or less oedema, and, in some cases of long standing, 
hyperplasia. Corresponding hematogenous changes are also mani- 
fested in the endometrium, which, at the menstrual epoch, is liable to 
become hemorrhagic, with a constant tendency to more or less metror- 
rhagia. When the displacement is associated with flexion interesting 
changes take place at the point at which the organ is bent. On its 



DISPLACEMENTS OF THE UTERUS 287 

under, or concave, surface, there occurs an amount of pressure, varying 
according to the degree of angulation, upon the bent and approximated 
surfaces, that sooner or later induces atrophy of the posterior uterine 
wall at that point. While these changes are occurring on the concave 
side of the uterus, opposite changes are noticeable on the upper or con- 
vex side, where the tissues, instead of being subjected to abnormal pres- 
sure, are in a state of unnatural tension. The anterior, or upper, wall, 
yielding to this tension, presently manifests appearances of compensa- 
tory hyperplastic development; the result is a thinned, relatively atten- 
uated, uterine wall on the one (concave) side, as opposed to the elon- 
gated and redundant wall on the other (convex) side. These are the 
cases that are persistent even in the absence of adhesions. In other 
cases, however, particularly those in which the displacement has fol- 
lowed upon a puerperal metritis, there seems to have occurred more or 
less fatty degeneration, with consequent loss of tone of the uterine 
parenchyma and resulting abnormal flexibility of the uterus, particu- 
larly at the cervico-corporeal juncture. In these cases the uterus may 
be found in a state of anteflexion one day, while the next day the 
surgeon will find the fundus in the cul-de-sac. Coincidently with 
these changes, others equally marked occur in the uterine ligaments. 
In many cases associated with intrapelvic infections it may be accepted 
as true, that the loss of tone due to inflammatory disturbances in the 
ligaments themselves constitutes the initial change in the development 
of uterine displacements; but, whether causal or sequent, relaxation 
with elongation of the ligaments sooner or later occurs. The utero- 
sacral ligaments, normally taut, become distinctly relaxed, permitting 
the cervix to go forward, while the round ligaments become stretched 
and permit the fundus to drop backward; or, the broad ligaments, the 
seat of an infiltration, cease to exercise control over the poise of the 
uterus. While these changes, essentially inflammatory in character, 
permit abnormal mobility of the uterus, it is to be remembered that 
sooner or later occur, in structures containing considerable connective- 
tissue elements, those contractions which ensue upon the absorption of 
inflammatory products. The essentially atrophic changes in this stage 
of the inflammatory process result in contractions more or less marked 
in all the involved structures except the round ligaments, and pro- 
ductive of more or less distortion of the uterus. If it were imaginable 
that these changes would occur coincidently and equally in all the sus- 
pensory structures of the uterus, it could be understood that that organ 
would thereby be drawn back to its normal position and so retained 
more firmly than before. Unfortunately for such a result, however, 
the round ligaments do not partake of the contractile changes, while 
adhesions generally take place by which the fundus becomes anchored 
in the cul-de-sac, to the wall of the bladder, or to a proximal surface 
of intestine; or, as too frequently happens, the exudation is so extensive 
as to involve, not only the uterus and the approximated peritoneal sur- 
faces, but also the Fallopian tubes and the ovaries, in the general agglu- 



288 A TEXT-BOOK OF GYNECOLOGY 

tination. Under these circumstances, the resulting inflammatory con- 
traction of any or all of the uterine ligaments can not do otherwise 
than develop counter traction, causing thereby an intensification of the 
general intrapelvic distress. Occasionally, the inflammatory process with 
the resulting adhesion occurs on but one side of the pelvis, or, if it occurs 
on both sides, one side undergoes resolution while the other side shows 
the mischievous results of exudation, adhesion and lateral displacement. 

The pathology of prolapsus of the uterus differs materially from 
that in which there exists a mere deviation from the normal axis 
without descent of the organ below its normal plane. It is indeed 
an open question whether prolapsus of the uterus should be patho- 
logically classified merely as uterine displacement; for, as a mat- 
ter of fact, the descent of the uterus in the pelvis is but little more 
than an incident in a series of broader and more comprehensive morbid 
changes. It is doubtful whether descensus uteri should be considered 
otherwise than as a feature of a general intrapelvic hernia. The pa- 
thology of this condition involves very generally an enteroptosis, a 
weakening of the suspensory apparatus of the uterus, and a relaxation of 
the pelvic diaphragm proper, with either a laceration or relaxation of 
the pelvic floor. The frequent occurrence of descensus uteri in women 
who have never borne children or who have never sustained sexual 
relations, indicates that this form of hernia frequently occurs inde- 
pendently of puerperal conditions. It may be held as true, however, 
that in the majority of cases, the impairment of all the structures in- 
volved in this condition is due to the accidents of childbirth. The exer- 
cise of undue force, involuntary, manipulative, or instrumental, may 
have done serious damage to the suspensory apparatus; or the undue 
distention of the cervix, resulting in its laceration or in the laceration 
of the circumuterine or perimetric fascia, or in damage to the floor of 
the pelvis (see Injuries of the Floor of the Pelvis), may have laid the 
foundation for this form of visceral extrusion. Injuries to the floor of 
the pelvis alone, if permitted to persist, may induce within the pelvis 
changes that will permit the descent of its contents. This occurs, not 
from the removal of any fancied support to the uterus, but from the 
widening of the vaginal outlet permitting the vaginal walls, the rectum, 
and the bladder, to descend and to exercise undue, and finally overpow- 
ering, traction upon the uterus and its normal attachments. It thus 
happens that injuries to the pelvic floor may be the primary and causal 
condition, while the reverse may be equally true. 

The Treatment of Uterine Displacements. — The idea that uterine 
displacements in themselves cause little or no harm is held now by 
very few gynecologists. The multitude of methods which have been 
devised for curing these displacements is proof that the vast majority 
of surgeons see in them something which needs correction. Mann takes 
it for granted that uterine displacements in themselves have an im- 
portant pathological bearing; that a woman with a displaced uterus 
can never be perfectly well, and that the malposition should, there- 



DISPLACEMENTS OF THE UTERUS 289 

fore, be corrected. This may be done in various ways. Unquestion- 
ably a certain proportion of downward and retro-deviations may 
be relieved by mechanical devices — pessaries of various kinds. But 
these, at best, are rarely curative, giving relief only while they are 
worn. To make a permanent cure, some surgical procedure is necessary, 
by which the natural supports of the uterus may be returned to their 
normal condition, or else some new support may be added, whereby 
the uterus shall be prevented from getting out of place. If there is 
any exception to what has been said, it is in regard to forward dis- 
placements. The tendency to their surgical treatment has diminished 
with time, and now very few operate for anteversion or anteflexion, 
except by dilatation and curetting. Still, there are cases where some 
other surgical operations seem to be demanded, and these will be con- 
sidered. Prolapse has been, and still is, a battle-ground as to the 
proper method of gaining permanent relief. 

It is the firm belief of Mann that more good can be done, with 
less risk, in the surgical treatment of uterine displacements than in 
any other branch of gynecological surgery. The mortality of these 
operations in themselves should be nil. Of course accidents may happen 
and an occasional death occur; but usually they may be considered 
as being in themselves without danger to life. The dangers, if any, 
must arise from the serious complications which are often coexistent 
with the displacement. 

Retro-deviations of the uterus are of frequent occurrence. The 
combined observations of Winckel, Lohlein, and Sanger, embracing 
several thousand patients, show that retro-deviations occur in 1T.74: 
per cent of all gynecologic patients. These displacements may cause 
no appreciable symptoms; or, on the other hand, they may create such 
disturbance that they may properly be classified among the most dis- 
tressing and persistent maladies with which a woman can be afflicted. 
They give rise not only to local discomfort but to constitutional ill 
health; they render a woman unfit for the marital relation and are the 
cause of sterility; and their prompt detection and effective treatment 
are among the most imperative duties devolving upon the practitioner. 

Symptoms and Diagnosis. — When retro-deviation occurs suddenly, 
as from a fall or a jump, the patient complains of pain low down in 
the back, sacralgia, and general pelvic discomfort. This discomfort 
may at times become a sharp lancinating pain. When the displace- 
ment is of longer standing, the patient complains of pain in the back 
and in the neighbourhood of the sacrum and the cocc} t x, often radiating 
down the legs, frequently into the external pudendal organs and often 
centring in the clitoris. This pain is exaggerated by walking, stair- 
climbing, or any laborious occupation. Dysuria is generally present, 
and the patient sooner or later complains of constipation. This latter 
condition is frequently associated with other disturbances of the diges- 
tive tract, causing impairment of the general nutrition, loss of flesh, 
and the general appearances of anaemia. The diagnosis, however, will 
20 



290 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 116. — "The examination should be made with 
the patient on her back and her head a little ele- 
vated." — Eeed. 



depend upon the physical conditions discovered by local examination. 
The examination should be made with the patient on her back and her 
head a little elevated (Fig. 116). Digital examination, particularly in 
the case of retroversion, will reveal a change in the uterine axis, mani- 
fested by anterior dis- 
placement of the cervix. 
If the ringer is now passed 
up toward the cul-de-sac, 
a mass will be felt. This 
may be due to a loaded sig- 
moid, a subperitoneal my- 
oma, an enlarged and dis- 
placed ovary, or a de- 
scended and distended 
Fallopian tube; or it may 
be the fundus of the 
uterus. At this point, the 
diagnosis will be material- 
ly facilitated by placing 
the other hand over the 
abdominal wall, when, if 
the condition is a retro-deviation, the fundus of the uterus will not 
be discovered in its normal situation. If the case is one of retro- 
flexion instead of retroversion, the point of angulation can generally 
be discovered by the tip of the intravaginal finger. In recent cases of 
uncomplicated retro-deviation, pelvic engorgement associated with 
pronounced tenderness may be present, and may temporarily mask the 
condition of the uterus. Eetro-deviations frequently exist as com- 
plications of myomata, and of inflammations, enlargements, and dis- 
placements, of the appendages. The sound was formerly employed 
as a means of diagnosis in these cases, but so much damage has fol- 
lowed its use that its employment in this connection has been aban- 
doned by judicious practitioners. An index finger may be introduced 
into the rectum whereby some additional information may be obtained. 
The diagnosis should, however, be made by means of the bimanual 
examination and without recourse to instrumental or other exploration. 
The treatment of retro-deviations consists in the application of 
topical, mechanical, and surgical, measures. The first step in the 
judicious application of any of these means of cure must consist in 
determining, with, at least, approximate accuracy, not only the exist- 
ence of the displacement, but of the various complications with which 
it may be associated. Thus, in the presence of a metritis, of acute 
inflammation of the Fallopian tubes, or of recent intense and painful 
general engorgement of the pelvis, all manipulations having for their 
object the reduction of the displacement should be interdicted. In 
the presence of these conditions, the patient should be put in the 
recumbent posture and should be treated with salines, hot douches, 



DISPLACEMENTS OF THE UTERUS 



291 




and glycerine tamponade, until the acute symptoms have subsided. 
When there are no contraindications reposition of the displaced organ 
should be undertaken. The patient should be placed in Situs's position 
(see Gynecological Examinations), or she may be placed in the knee- 
elbow posture (Fig. 117). With the index finger passed toward the 
cul-de-sac and pressing against the fundus, that portion of the uterus 
in the absence of adhesions may be readily thrown forward. The 
manipulation is sometimes assisted by pressure directed toward the 
cervix, the hand being placed above the pubes for this purpose. The 
index finger passed into the rectum will enable the operator to manipu- 
late the fundus of the uterus with more .force and precision. The 
various so-called uterine re- 
positors are to be looked 
upon as expedients of more 
than doubtful safety. The 
old practice of introducing 
a curved uterine sound and 
of then turning it round in 
the uterine cavity thus forc- 
ing the uterus back into po- 
sition, has been denounced 
by intelligent gynecologists 
and abandoned b}^ consci- 
entious practitioners. The 
practical impossibility of 
introducing a uterine sound 

without making it the bearer of pathogenic germs, and the extreme 
probability of establishing an infection atrium by its use, indicate a 
danger the reality of which has been confirmed by more deaths than 
have been honestly recorded. 

Massage has been employed in the treatment of these cases. This 
consists in a series of intrapelvic manipulations effected by means of 
bimanual operation, whereby the uterus is subjected to pressure and 
the contracted ligaments and adhesions undergo tension. (See Mas- 
sage.) It goes without saying that this method of treatment is contra- 
indicated in the presence of infectious conditions of the uterine adnexa 
and of the pelvic lymphatics. The extreme difficulty of detecting these 
conditions renders massage a dangerous remedy, a fact which is con- 
firmed by its general abandonment by the profession. Electrolysis, as 
employed in these cases, consists in the application of strong currents 
of electricity, for the purpose of causing the absorption of plastic de- 
posits and of the utero-peritoneal adhesions associated with retro-de- 
viations. Its method of application implies the repeated introduc- 
tion of an electrode into the uterus, a fact which, of itself, renders it 
undesirable as a systematic treatment. Tamponade is an expedient of 
great value in the treatment of these cases. If the tampon is carefully 
applied and is of the proper material, it will furnish to the displaced 



Fig. 117. 



She may be placed in the knee-elbow 
posture. ,, — Reed. 



292 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 118. — "A tampon which amounts to nothing more or 
less than a large plug on the vagina." — Reed. 



uterus an important mechanical support, while, if saturated with 
glycerine, the exosmotic property of the latter will exercise a valuable 
influence in effecting the absorption of inflammatory exudates. 

A tampon, however, 
which amounts to 
nothing more or less 
than a large plug in 
the vagina (Fig. 118), 
and which is large 
enough to distend the 
vulvar orifice when it 
is removed and re- 
quires considerable 
traction to remove it, 
is always a source of 
damage. The repeated 
downward traction 
thus exercised upon 
the vaginal wall has a 
tendency to drag the uterus downward in the pelvis and thus to aggra- 
vate the very condition that it is designed to remedy. A tampon 
properly adjusted should occupy the upper portion of the vagina, 
should not exercise 
enough pressure to oc- 
casion discomfort, and 
should be so con- 
structed that its re- 
moval will not involve 
traction upon the pel- 
vic viscera. The well- 
known chain tampon 
(Fig. 119) is very 
good; but a better one 
consists of a long nar- 
row roll of either 
lamb's wool or cotton, 
with the fibre running 
lengtlrwise, and with 
a string attached at 
one end (Fig. 120). 
The ends of the string 
are left about 6 inches 
long. A strand of 
silkworm gut used for 

this purpose is very desirable because of its lack of porosity. The 
tampon, 10 or 12 inches long, or even longer, is now passed into 
the vagina through a speculum, care being taken that it does not 




Fig. 119. — " The well-known chain tampon is very good. 
— Reed. 



DISPLACEMENTS OF THE UTERUS 



293 



extend far enough down in the canal to occasion tenesmus. When 
such a tampon is removed, but little effort is required, and the patient 
makes no complaint of the dragging and pulling that is the unpleasant 
feature in the removal of one that 
is improperly constructed. (See 
Nonsurgical Treatment of Sal- 
pingitis.) 

Pessaries have long been em- 
ployed as a means of retaining 
the replaced uterus in position. 
In the decades preceding the ad- 
vent of the present successful 
surgery of the pelvis, pessaries 
were very generally employed in 
the treatment of retro-deviations 
and cures were reported from 
their use. So much manifest in- 
jury, however, came from their 
employment that it has been very 
largely abandoned. Of the vari- 
ous pessaries employed in the 
treatment of this condition, one 
devised by Albert Smith for in- 
travaginal application, and one by 
Gaillard Thomas for extravaginal 
support, were probably the most 
successful. If pessaries are em- 
ployed the following axioms 
should be observed: An intra- 
uterine stem should never be 
used; no pessary should be ad- 
justed in the presence of either 
local or general inflammation 
within the pelvis ; no pessary 
should be adjusted to an unre- 
duced displacement; and no pes- 
sary should be continued in posi- 
tion after it begins to cause pain. If these rules are carefully observed 
it will be discovered that there are but very few pessaries that are 
adapted to the treatment of these cases. 

J. Whitridge Williams {Maryland Medical Journal), while contend- 
ing for the value of pessaries, says that it can not be asserted that they 
will "cure the trouble in all cases, even when we are able to replace the 
uterus. Indeed, the contrary must be confessed, if by cure we mean 
that the pessary will enable the uterus and its supporting structures 
to reassume their normal tone, and at last remain in place without its 
assistance. Such a result may be designated as an absolute cure, and 




Fig. 120. — " A better tampon consists of a 
long narrow roll of either lamb's wool 
or cotton, with the tibre running length- 
wise, and with a string attached at one 
end." — Eeed (page 292.) 



294 A TEXT-BOOK OF GYNECOLOGY 

only occurs in about 25 per cent of the cases treated. On the other 
hand, in a much larger proportion of cases, the uterus remains in 
place and all the symptoms are removed as long as the pessary is 
employed, but recur as soon as it is removed. These we may designate 
as relative cures, and they occur in from 40 per cent (Sanger) to 60 
per cent (Klotz) of all cases conscientiously treated." 

The Surgical Treatment of Retro-deviations. — Many methods have 
been devised for the curing of backward displacements of the uterus. 
These may be included under three headings: First, Shortening the 
Round Ligaments; secondly, Ventral Fixation or Suspension; and, 
thirdly, Vaginal Fixation, as introduced by the German operators. 

Shortening the Round Ligaments. — The idea of shortening the 
round ligaments for the cure of backward displacements of the uterus 
was first suggested, by Alquie, of France, in 1840. This suggestion was 
not favourably received, and it was not until Alexander, of Liverpool, 
successfully performed the operation and carefully described the pro- 
cedure, that the operation was accepted. Adams performed the opera- 
tion independently a few months later; but it was undoubtedly Alex- 
ander's monograph, published in 1884, which induced other operators 
to follow his example, and placed the operation on a firm basis. 

The idea of shortening the round ligaments internally originated 
with W. G. Wylie, of New York, who operated first in 1886. Bode, in 
1888, did a very similar operation. Ruggi and Frank, also, did analo- 
gous operations about the same time. The operation has been further 
modified by Polk, Palmer Dudley, M. Baudouin, Mann, and others. 

The shortening of the round ligaments through a vaginal incision 
was first done by Wertheim, and his procedure has been modified and 
improved upon by Bode and Kiefer, in Berlin, and by Byford, Vine- 
berg, and Goffe, in this country. 

The original operation of Alexander has stood the test of time and 
experience, and, with slight modifications of technique, is done by all 
who operate from the outside. Within the abdomen, the operation of 
Mann is accepted by many as the best; and through the vagina, the 
few who have operated in this country have generally followed either 
Byford or Goffe. As it is not necessary to describe the various steps in 
the evolution of these operations, only the three named will be fully 
described. 

Alexander's Operation — Indications. — Alexander's operation may 
be properly performed in any backward or downward displacement in 
which there are no adhesions. Should adhesions exist, if not too 
numerous, they may be broken up before the operation, either by the 
conjoined manipulation, or, better still, by an incision through the 
posterior wall of the vagina into Douglas's pouch. When adhesions 
are present, there is usually, also, associated disease of the tubes and 
ovaries; so that in the majority of the cases of this kind, in Mann's 
opinion, abdominal section with intra-abdominal shortening of the liga- 
ments is the better operation. 



DISPLACEMENTS OF THE UTERUS 295 

Where the uterus is greatly enlarged and the utero-sacral ligaments 
are also relaxed, very little benefit can be expected to follow Alex- 
ander's operation alone, because, although the fundus may be held for- 
ward, the cervix will slide down under the symphysis and the uterus 
will again get into the axis of the vagina, so that, in time, the round 
ligaments will give way, and the displacement will recur. In these 
cases it may be necessary for the patient to wear a pessary for some 
time after Alexander's operation, or the utero-sacral ligaments may 
be shortened, or Pryor's plan of opening into Douglas's pouch and 
packing this with iodoform gauze may be followed. (See page 305.) 

Antiseptic Precautions. — It has been the experience of many opera- 
tors that suppuration is quite prone to occur in this operation. This 
can be readily accounted for by the low vitality of the parts involved — 
adipose tissue and tendon — by the great amount of handling of the 
tissues, and by the depths of the cutaneous folds affording safe hiding 
places to the Staphylococcus pyogenes alius and other micro-organisms. 
Suppuration can generally be prevented by a very rigid asepsis. Un- 
questionably, the fingers of the surgeon are the great carriers of infec- 
tion. While experiments show that it is impossible to perfectly steril- 
ize the fingers, still, the dangers can be reduced to a minimum by care- 
ful scrubbing with soap and hot water, and subsequent immersion for 
at least five minutes in a l-to-1,000 sublimate solution, or in the 
potassium permanganate and oxalic acid solutions. 

The use of rubber gloves is the most certain way of preventing in- 
fection from the hands, and they should never be omitted. In a long 
series of cases done with gloves, not a single suppurative case has been 
met with. While the gloves at first seem to be a great obstacle, after 
a little practice their presence is scarcely noticed. 

The most thorough disinfection of the patient's skin should be 
employed. After careful shaving, the parts should be covered with a 
green-soap poultice for some hours, and then thoroughly scrubbed, and 
a cloth wet in sublimate solution (1 to 1,000) placed over them and 
left there until the operation begins. Immediately before the opera- 
tion, an additional scrubbing with alcohol and ether, followed by 
more sublimate solution, will diminish the chances of suppuration. 
During the operation all loose pieces of fat, torn muscle, or fascia, 
should be removed, and all blood vessels carefully tied or twisted, so 
as to prevent the formation of clots as far as possible. It must not be 
forgotten that the cut end of the ligament sometimes bleeds and may 
need a fine ligature. 

The present technique of the operation shows that no improve- 
ments of importance have been made in the original plan suggested by 
Alexander. The patient, being properly prepared, is placed upon the 
table with the feet toward the light. The uterus must first be carefully 
replaced and a pessary introduced. In most instances it will be advis- 
able to precede this by a thorough curettage of the uterus. Should 
there be a thorough retroflexion, it may sometimes be necessary to 



296 A TEXT-BOOK OF GYNECOLOGY 

introduce a stem pessary, in order to make the uterus rigid and to pre- 
vent the fundus from turning over round the pessary. 

Having thoroughly cleansed the skin at the seat of operation and 
surrounded the parts with antiseptic towels, wet or dry as the opera- 
tor may choose, either the spine of the pubis or the external abdominal 
ring is felt for. One or both can usually be readily distinguished. 
An incision is then made directly over the ring, a short distance above 
Poupart's ligament and parallel to it. The length of the incision will 
vary with the amount of adipose tissue present. In many thin persons, 
the incision may be less than an inch in length; two inches is the 
maximum length in any case. The fat and superficial fascia should be 
carefully incised until the tendon of the external oblique muscle is 
clearly and distinctly visible. This may be recognised by its white and 
glistening appearance. Between the fibres of this tendon may be seen 
the covering of the inguinal canal, which is recognised as a somewhat 
darker line slightly triangular in shape. The finger tip readily recog- 
nises the external ring. 

With the scissors the intercolumnar fascia at the external ring 
is snipped, and immediately a small mass of fat will extrude itself. 
This may be picked up between the thumb and finger and slowly and 
carefully raised; or, should the operator prefer, a strabismus hook may 
be introduced and the tissues within the canal brought forward. These 
tissues always contain the cord spread out in fan-shape. By raising 
them carefully, the whitish fibres of the cord may be recognised. It 
should then be separated from the surrounding connective tissue and 
also from the nerve. The nerve should not be cut, but carefully laid 
aside. Then, with the fingers alone, without the use of any instrument, 
the cord should be slowly and carefully pulled out. In the majority 
of instances it comes out readily, increasing in size as the lower por- 
tions are brought up, until a large, white, fibrinous, structure is 
brought well in view. In some instances the pubic portion of the cord 
is exceedingly small and requires the most careful handling; but, if 
great care and delicacy are used, it may be slowly and gradually 
brought out until the large and well-developed cord is finally secured. 
If the cord comes with great difficulty, the intercolumnar fascia may 
be incised and the whole length of the canal laid open, thus exposing 
the cord at a point where it is usually larger and stronger. 

Having been once brought out, the cord is allowed to fall back into 
its place, the pubic end being still connected, and the same procedure 
is followed upon the opposite side. Most operators prefer to change 
sides, and to stand upon the side on which they are operating. 

The length to which the cord should be pulled out varies. In 
simple retroversions, a moderate amount of shortening is all that is 
needed. Should the parts be very much relaxed and the uterus en- 
larged and prolapsed, a greater amount of shortening will be required. 
No positive rule can be given for this; the judgment of the operator 
must decide in each case. Both cords being loosened and all hemor- 



DISPLACEMENTS OF THE UTERUS 297 

rhage stopped, the pubic end of one cord is cut close to the pubis, and 
the cord drawn out and held by an assistant, well up to the abdominal 
wall. A stitch of catgut is passed through one pillar of the ring, and 
then through the cord and the opposite pillar. The same stitch is then 
passed through these tissues in reverse order, the two ends being 
brought out on the same side. This mattress suture serves to keep 
the cord in place and effectually to close the canal. The cord is then 
cut off half an inch beyond the last stitch. Should the inguinal canal 
be still open to any extent, this should be closed by additional catgut 
stitches. 

This procedure having been completed on both sides, the wounds 
are closed by deep stitches of fine catgut. An antiseptic dressing is 
applied and held in j^lace by adhesive straps. The bandage devised by 
Dr. Kelly, and known by his name, has proved very serviceable in still 
further holding the dressings in place. 

There are several complications to be taken into account Adhesions 
in the inguinal canal sometimes effectually prevent the drawing out 
of the cord. In three cases seen by Mann, the cord was so firmly 
attached on one side, that it was impossible to draw it out, there 
having been in each case an inflammatory condition with pus-formation 
in the neighbourhood of the canal. Upon the opposite side, in each 
of these cases, the cord was drawn out as usual. It is questionable 
whether the operation should ever be undertaken under such circum- 
stances. The shortening of one cord is hardly sufficient to keep the 
uterus in place, although it may help, and occasionally succeeds per- 
fectly. 

We can never predict whether we shall encounter a delicate cord or 
a strong one, in any given case. In young women who have never 
borne children, or in whom the uterus is not well developed, the liga- 
ments are sometimes very small and ill defined. In women who have 
passed the menopause, and in whom the uterus is atrophied, the atrophic 
process seems often to include the round ligaments; and in these eases 
the result of Alexander's operation is not so sure. From these or 
other causes, the cord is at times so delicate, especially at the pubic 
end, as to be pulled out with the greatest difficulty. Unless the utmost 
gentleness is used, it will be broken, and then all clew to its position 
is lost. By working very slowly and carefully, and opening up the 
inguinal canal to its full extent, the cord can usually be pulled out, 
even in the worst cases. Considerable time must be taken, as hurry 
will surely result in failure. 

In a few instances the cord will break. If this occurs at the pubic 
end, and the uterine end of the cord can be kept in view, it may be 
carefully followed up until it becomes large enough to be firmly seized 
and so be pulled out. It is impossible to pull upon the cord with a 
hemostat or any instrument, for, no matter how carefully it is clone, it 
will crush and cut the cord. The cord must always be pulled with the 
fingers, and the fingers alone. As the gloved fingers are slippery, it 



298 A TEXT-BOOK OF GYNECOLOGY 

is well, until the cord is entirely loosened, to keep its pubic end attached. 
In pulling on the cord, it must always be remembered that the force 
should be applied in the direction of the inguinal canal. 

If the uterine end of the cord breaks after it has been nearly freed, 
the difficulties of securing it again are very great. The only chance 
then will be to follow up the inguinal canal and to open into the 
abdominal cavity through the internal ring. Goldspohn, of Chicago, 
recommends that the internal ring should be opened in all cases, and 
he inspects and operates upon the tubes and ovaries in this way. Mann 
has performed this operation several times, removing diseased ovaries 
and tubes before shortening the round ligaments. It does not seem 
to be generally advisable to adopt this procedure, as the median opera- 
tion, with the internal shortening of the round ligaments, would seem 
to be safer and easier. By pulling up the horn of the uterus, the 
broken end of the round ligament may sometimes be found; but the 
operation may fail because the cord is broken so close to the uterus 
that there is not sufficient to sew even to the internal ring. 

The operator is sometimes embarrassed by anatomical abnormi- 
ties. In a few instances, the cord has been found not to run through 
the inguinal canal. Doubt may be thrown upon some of these cases, 
as only the most careful dissection post-mortem would be sufficient to 
prove that the cord is not there. Failure to find the cord will be less 
frequent as the operator becomes more experienced. By keeping the 
anatomic landmarks carefully in view, and by making sure that the ten- 
dons of the external oblique muscle, with the external ring, are clearly 
exposed, and that the incision is made between the pillars of the ring 
and not to one side, very few failures will be encountered. In about 
1 per cent of cases the canal of Nuck will be found to be open from 
the internal ring to the symphysis. In these cases the round ligament is 
always found embedded in the walls of the canal and can not be sepa- 
rated, and the shortening of the ligaments is impossible. The fact that 
there is a persistent canal of Nuck on one side does not prove that the 
same condition exists upon the opposite side. Inguinal hernia in the 
female is comparatively rare, but, when found, often coexists with re- 
troversion. In these cases, the shortening of the round ligaments and 
the cure of the hernia can be done together. The round ligament will 
usually be found upon the hernial sac, and must be carefully searched 
for before the sac is cut off. 

The after-treatment is very simple. The patient should be kept in 
bed for eight or ten days, and the wound left untouched, unless the 
temperature goes up. At the end of that time the dressings may be 
removed; when the wound should be found perfectly healed. Upon 
the tenth day, the patient may be allowed to sit up, and may leave her 
room as soon after as her strength will permit. The pessary which 
was introduced at the time of the operation should be worn for two 
or three months; and, if there is much relaxation of the utero-sacral 
ligaments, it may be necessary to keep it in for a longer period. 



DISPLACEMENTS OF THE UTERUS 



299 



Intra-abdominal Shortening of the Round Ligaments — Mann's 
Operation. — The operation here to be described is a modification of 
the procedure first suggested by Wylie (Fig. 121). It has been de- 
scribed by Mann in the American Gynecological Transactions for 1897. 
It was first done in June, 1893. 

The special indications for this operation are a backward displace- 
ment and such complications with other diseased conditions as to make 
the opening of the abdomen advisable. It can be done, therefore, 




Fig. 121.—" The procedure first described by Wylie. 1 '— Mann. 



where it is necessary to open the abdomen for reparative work on dis- 
eased tubes and ovaries, for the breaking-up of adhesions, the removal of 
one tube and ovary, or the removal of ovarian cyst or pedunculated 
fibroid. It may also be done when Alexander's operation has been tried 
and has failed, or is contraindicated for any reason. In any abdominal 
section for pelvic disease, if the uterus is displaced backward, this or 
some operation having a similar purpose should be done. Where both 
tubes and ovaries are removed, or when pregnancy can not possibly 
occur, some might prefer ventral fixation. This operation does not com- 
pete with Alexander's operation, as it fulfils entirely different indications. 

The abdomen being opened, the technique of the operation is as 
follows: Adhesions are broken up, and any other necessary operative 
procedure completed. The patient is then placed in the Trendelen- 
burg position, and the abdominal retractors put in place. A large, 
flat sponge is spread over the intestines, and the uterus is seized by a 
small volsella forceps and pulled up to the abdominal wound. The 
round ligament on one side is made tense by pulling the uterus to the 
opposite side, and is then seized by two hemostatic forceps, the points 
of seizure dividing the ligament as nearly as possible into three equal 
portions. 

Next, a needle, threaded with silk, is passed through the angle in 
the round ligament made by pulling upon the hemostat. This passes, 
therefore, twice through the ligament at points quite near to each 
other. It is then passed through the wall of the uterus at the point 
where the round ligament is inserted into the anterior uterine wall. 
It is well that a considerable quantity of uterine tissue be included in 
this suture. The usual method of passing the sutures through the 
anterior wall of the uterus is wrong (Fig. 122). 



300 



A TEXT-BOOK OF GYNECOLOGY 



The hemostat being removed, the loop of the ligament is tied to the 
uterus. A second stitch is passed through the ligament just as it 
leaves the abdominal wall, and then through the second angle in the 
round ligament at the site of the other forceps. This ligature is tied 




Fig. 122. — " The usual method of passing the suture through the anterior wall of the 
uterus is wrong." — Mann (page 299). 

and cut as before. In this way the ligament is doubled on itself, and 
three thicknesses of round ligament are stretched between the sides 
of the pelvis and the wall of the uterus. The same thing being done 
upon the opposite side, the wound is closed in the usual manner. 

Reed has adopted Mann's operation 
as the one of choice in practically all 
retro-deviations of the uterus. He em- 
ploys a forceps, having four flat approxi- 
mating prongs, the whole being an inch 
or more wide, with which to seize the 
round ligament in its middle (Fig. 123). 
A half turn of the forceps makes the de- 
sired fold in the round ligament (Fig. 
124). The folds of the ligament are now 
fixed at the uterine and parietal ends as 
already described, interrupted sutures 
being employed; the middle zone is next 
fixed by a continuous suture passed be- 
tween the prongs of the forceps. The 
result is a triplicate ligament of desirable 
shortness and great strength (Fig. 125). 
The character of the suture material 
with which the round ligaments are 
sewed up is of some importance. Silk- 
worm gut is satisfactory, and has been 
used in many cases without harm; and, 
should an abscess occur and the removal of the suture be found neces- 
sary, it can be more easily found than a suture of any other material, 
as the sharp cut ends can be appreciated by the sense of touch. Catgut, 
which is readily absorbed, may produce adhesions, but the adhesions are 




Fig. 123.—" A forceps with four flat 
approximating prongs, the whole 
being an inch or more wide." 
— Reed. 



DISPLACEMENTS OF THE UTERUS 



301 



not always permanent, and some cases of failure, or, rather, of recur- 
rence, have been reported. In one case operated on by Mann, in which 
catgut was used, in the year subsequent to the original operation all 
traces of the doubling of 
the ligaments had disap- fig 
pearecl. For this reason 
an unabsorbable ligature 
seems preferable. 

The results as shown 
by a number of cases 
which have been reported 
by different operators 
have been satisfactory. 
When pregnancy has oc- 
curred after this opera- 
tion, the labour has been 
entirely normal in each 
instance. As the uterus 
is held in its normal posi- 
tion, and as the round 
ligaments can stretch and 
grow as well as they could 
were they not stitched to- 
gether, there is no reason 
why pregnancy and la- 
bour should be interfered 
with in any way by this 
operation. 

The after-treatment is 
that which is usual for 
cases of abdominal sec- 
tion. 

For those who prefer 
the vaginal route, the op- 
erations of Goffe or Byford for shortening 1 of the round ligaments 
through the vagina are practical and give good results, though they are 
confessedly more difficult of performance than where the round liga- 
ments are shortened through an abdominal incision. 

For those who are skilled in vaginal work, this operation may be 
indicated whenever the uterus is displaced, whether there are adhesions 
and tubal and ovarian disease or not. Unless the adhesions are very 
dense and the disease of the adnexa extensive, they can all be treated 
through the vagina, thus widening materially the indications for this 
operation over that of Alexander, and bringing it in direct competition 
with the abdominal operation. 

Gaffe's Operatian. — Goffe, after placing the patient in the dorsal 
position, with the thighs well flexed, seizes the cervix through a specn- 




Fig. l-2-i. — •• 
desired folc 



\. half turn of the forceps now makes the 
in the round ligament." — Reed (page 300). 



302 



A TEXT-BOOK OF GYNECOLOGY 



lum, and pulls it strongly away from the pubis. An incision is then 
made halfway round the uterus, through the vaginal wall. Another 
incision at right angles to this, in the median line, converts the opening 
into a T-shaped incision. Through this, the bladder is carefully sepa- 
rated from the vaginal wall by the finger, and the peritoneum opened. 

The fundus of the uterus 
is next pulled down until 
the round ligaments are 
brought into view. They 
are then doubled upon 
themselves in two places, 
much as in Mann's opera- 
tion. It is impossible, 
however, to get the out- 
side stitch as near the 
pelvic wall as is done 
when the abdomen is 
opened. Otherwise, the 
operation is practically 
the same. With the 
uterus pulled down 
through the vaginal 
wound, the tubes and 
ovaries can be inspected 
and operated on, if de- 
sired, and adhesions 
broken. After the liga- 
ments have been short- 
ened, the vaginal wound 
is closed with catgut su- 
tures and a small open- 
ing for drainage left, 
if thought desirable, 
though usually this is 
unnecessary. The vagina 
is then dusted with iodo- 
form, and the patient 
placed in bed. 
Byford's operation differs from the procedure of Goffe in that he 
draws down the fundus of the bladder and stitches the fundus of the 
uterus to the post-pubic peritoneum, which is drawn down after the 
bladder but recedes upward when released, and draws the fundus 
with it. The fundus is thus sutured to the peritoneum over the blad- 
der, much in the same way as in abdominal hysteropexy. 

For the suture of the bladder to the fundus, he uses formalinized 
catgut, placing two stitches about an inch apart. He draws down the 
round ligaments and uterine horns into the vagina, suturing the for- 




Fig. 125. — " The result is a triplicate ligament of desir- 
able shortness and great strength." — Eeed (page 300). 



DISPLACEMENTS OF THE UTERUS 303 

mer as taut as possible to the uterus just above the uterine insertion. 
As he finishes the suturing of the ligament, he throws the same catgut 
thread around the neck of the loop thus formed, and ties it securely. 
This last step he considers an important detail. He pays no attention 
to the remainder of the loop, which forms adhesions to the bladder 
and uterus just below the sutures. After all intraperitoneal oozing has 
ceased, he closes the peritoneum with fine catgut and the vaginal wound 
in the ordinary way. 

Byford asserts that the simple shortening of the round ligament is 
not sufficient, because, if it depends simply on adhesions, these ad- 
hesions will stretch and give way, and allow a recurrence of the dis- 
placement. This objection does not hold if a nonabsorbable ligature 
is used in the shortening of the ligaments. Byford reports a number 
of cases with generally satisfactory results. 

The principal complication which is likely to give trouble is narrow- 
ness of the vagina. This is particularly the case in virgins and in 
women past the change of life, in whom atrophy has occurred. The 
narrow vagina makes the operation very much more difficult, and may 
be a positive contraindication unless the operator is an adept. Exten- 
sive disease of the tubes or ovaries may also contraindicate this .method 
of operating, and may even, where it has been begun, necessitate its 
abandonment, and the opening of the abdomen instead. 

This method has the great advantages of rapid recovery, absence of 
an unsightly scar, and freedom from danger of ventral hernia. As 
compared with the abdominal operation, it is more difficult of perform- 
ance, requires a large experience in vaginal work, and occasionally it 
is even necessary to open the abdomen to complete it — this, however, 
only in the presence of formidable complications. As compared with 
Alexander's operation, it is much more difficult and more dangerous. 
In simple cases the vaginal operation should always give way by prefer- 
ence to the Alexander. 

Vaginal Fixation. — Fnder this heading Mann includes all those 
operations which have for their purpose the fixation of the uterus 
through the vagina. Either the body or the neck of the uterus can be 
fixed directly; or it can be fixed indirectly by acting upon the vaginal 
walls. 

Fixation of the fundus originated with Eabenau (1886); but at pres- 
ent there are a number of methods of performing it in use, and no one 
fixed method seems to be generally adopted. The operation employed 
ly Mutter is as follows: After curetting in the usual way, the uterus is 
pushed into a position of anteflexion by means of Orthmann's instru- 
ment, and drawn strongly downward. (See Macnaughton Jones, 
Diseases of Women.) The anterior vaginal wall is then cut from the 
point of insertion into the cervix almost to the meatus urethral If a 
cystocele is present, an oval of mucous membrane upon the anterior 
vaginal wall is removed. The bladder is then separated from the 
vagina, the former being drawn up and held by a retractor. Great care 



304 A TEXT-BOOK OF GYNECOLOGY 

must be taken to have the bladder thoroughly separated, in order to 
avoid injury by suture or pressure by the uterus. The fundus is then 
reached, and half a dozen strong catgut sutures are next passed trans- 
versely in the anterior uterine wall, beginning at the wound above. 
The points of entrance and exit of the stitches are 2 centimetres apart. 
Then these stitches are carried through the edges of the wound, 1 centi- 
metre from the margins. The sutures are not tied yet, but the vaginal 
wound is closed; after which Orthmann's instrument is removed and 
the sutures tied in the order of insertion. The uterus, being in a posi- 
tion of anteversion, is held there by a firm tamponade of the vagina 
with iodoform gauze. In Mackenrodtfs operation, after separation of 
the bladder from the uterus and the opening of the abdominal cavity, 
the anterior flap of the peritoneum is stitched to the front of the 
uterus, and then to the posterior surface of the bladder, thus closing 
the vesico-uterine pouch. A. Martin does an intraperitoneal vaginal 
-fixation after colporrhaphy in a somewhat similar way. In this coun- 
try, Vineberg has practised an operation which involves both the short- 
ening of the round ligaments and the anterior fixation of the uterus. 
All of these operations of anterior fixation have the very great dis- 
advantage that they interfere more or less with pregnancy; and in the 
earlier cases, where the fundus was fixed to the vagina, very serious 
results followed. These earlier methods have been almost entirely 
given up, and seem to have very little place in gynecological practice. 

Besides the methods described, there are a variety of others, each 
operator seeming to have a plan of his own. It is not thought advisable 
to multiply descriptions of slight modifications of technique. 

Fixation of the cervix has been attempted, the object being to fasten 
it back in the hollow of the sacrum. It can be readily understood that, 
if the cervix is held upward and backward in the sacrum, the fundus 
will be thrown forward. This may be clone either by shortening the 
utero-sacral ligaments, or by causing adhesions between the posterior 
surface of the cervix and the rectum — in other words, by obliterating 
Douglas's cul-de-sac. The operation for shortening the utero-sacral 
ligaments has not been successful, no technique having been developed 
which could make the operation available. Mann made attempts to do 
this a number of years ago, putting the patient in the Trendelenburg 
position. In this way each utero-sacral ligament was folded upon 
itself and sewed with catgut. In some cases it may be done with com- 
parative ease, but in the majority of cases it is a very difficult matter, 
and the results have not been altogether satisfactory. Freund has 
proposed to shorten these ligaments by sewing them to the posterior 
wall of Douglas's pouch. Probably the best operation is that sug- 
gested by W. E. Pryor. His plan is as follows: 

Pryor's operation is done by preparing the patient locally and gen- 
erally as for a capital operation. After the uterus is curetted, the cul- 
de-sac is opened, the patient being in the dorsal position. If no pus 
is found, the operation is then continued. The tubes and ovaries 



DISPLACEMENTS OF THE UTERUS 305 

are treated as circumstances may require. After this, the pelvis is 
wiped dry and a gauze pad inserted. The patient is placed in the 
Trendelenburg position and the gauze pad removed. After the uterus 
has been packed with iodoform gauze, a piece of the gauze suffi- 
ciently vide to fill the vaginal opening, and about an inch and a half 
long, is inserted just within the edges of the vaginal wound. Over this 
enough strips are placed to fill the incision in the vagina. The uterus 
is then put in place, the gauze plug being carefully retained in position. 
Holding the uterus in place by the tampons pushing against the cervix, 
pieces of gauze are inserted to the sides of the cervix and in front of 
it, until the vagina is filled to the margin of the levator-ani muscle. 
The operator now takes a stout roll of gauze, as thick as his thumb, 
and about two inches long. This Pryor calls the gauze pessary. One 
end of this is introduced in front of one side of the cervix, just behind 
the levator-ani fibres, and the other end is pushed into a similar posi- 
tion on the other side. This plug lies transversely across the vagina 
and in front of the cervix. It will prevent the descent of the cervix, 
even in the face of the most severe vomiting. The uterine packing 
should be so arranged that it can be removed without disturbing the 
anchoring plug. (Fig. 36, p. 120, Pelvic Inflammations, Pryor.) 

A self-retaining catheter is introduced and is left in for two days. 

The after-treatment is important. In from seven to ten days, the 
patient is placed in Sims's position and all the dressings are removed 
and replaced exactly as they were at first. The operation will fail 
unless the supporting plug is properly inserted. Dressings are con- 
tinued as long as there is any raw surface in the vaginal vault. The 
supporting tampon is used for six weeks. The cervix must be kept 
pressing high and backward until the cul-de-sac opening closes and 
the posterior cervical scar is healed. 

Among the advantages claimed for this operation are that it leaves 
the corpus uteri perfectly in place, pregnancy is uninterrupted, and 
labour normal. The laceration and diseases of the cervix and peri- 
neum, according to Pryor, are to be corrected by subsequent operations, 
and not done at the time of the cul-de-sac operation. This is certainly 
a disadvantage as compared with Alexander's operation, which may 
very properly be joined with the various plastic operations on the 
vagina, cervix, and perineum. 

This operation may be clone in any case of retroversion, and is espe- 
cially indicated when the utero-sacral ligaments are relaxed, particu- 
larly in cases of retroversion with prolapse. It may be combined with 
Alexander's operation in cases of great relaxation. When the back- 
ward position is accompanied by occluded tubes, by hydrosalpinx, or by 
cystic ovaries, Pryor thinks this is the preferable operation; but when 
pus is present in either tube or ovary, he thinks laparotomy preferable. 

Ventral Fixation. — Under this head it is proposed to consider all 
the operations by which the uterus is fastened, either directly or indi- 
rectly to the abdominal wall. According to Delageniere, this opera- 
21 



306 A TEXT-BOOK OF GYNECOLOGY 

tion was first done in 1869, by Koeberle, who, after removing an ovary, 
fastened the pedicle into the abdominal wound. Lawson Tait first 
fixed the body of the uterus to the abdominal wall by passing a ligature 
through the fundus and through the edges of the wound. These two 
operations represent the direct and indirect methods which have been 
developed by later operators. 

Direct fixation of the fundus to the abdominal wall may be accom- 
plished in two ways — either by passing ligatures so as to simply ap- 
proximate the peritoneal surfaces; or the fundus may be sewed to 
other structures of the abdominal walls. In the first method the suture 
is passed first through the fascia, subperitoneal fat and peritoneum, 
and then through the posterior wall of the uterus a little below the 
fundus. It then passes through the opposite edge of the wound, com- 
ing out above the fascia. A similar stitch is passed a quarter of an 
inch nearer the umbilicus and a little lower upon the uterine wall. 
These stitches, when tied, approximate the posterior surface of the 
fundus to the abdomen; adhesions then form, and in time the perito- 
neum pulls down, forming what has been described as a " suspensory 
ligament." 

The second method is employed in cases of great enlargement of 
the uterus, and particularly in cases of prolapse, in which the adhesions 
formed by the first method are not sufficient to permanently support 
the uterus. Under these circumstances, it is well to attach the uterus 
more firmly. It may then be drawn out of the abdominal wound and 
the peritoneum sewed with a running suture entirely around the fun- 
dus, going farther down upon the posterior wall than upon the ante- 
rior. In this way half an inch of the fundus is brought above the 
peritoneum. It is then sewed firmly with buried catgut stitches to the 
fascia and the edges of the recti muscles. In this way very firm 
adhesions are formed and the most obstinate case of prolapse may be 
relieved. Kelly inserts the sutures through the peritoneum and fascia 
in such fashion that, when tied, the knots are within the peritoneal 
cavity (Fig. 126). In Mann's experience this method is satisfactory, 
but should never be performed in cases where pregnancy may possibly 
occur. It is especially indicated in women past the menopause, in 
whom very great relaxation of the vagina and perineum exists. 

The needle which should be used in this operation should have no 
cutting edge. The needles known as Emmet's vesico- vaginal-fistula 
needles are particularly appropriate, having large eyes and a round 
body with a slight curve. If such needles are used no hemorrhage will 
occur from the puncture of the uterine tissue. If the uterus is 
brought up against the line of the abdominal incision, sufficient adhe- 
sions will take place. If, however, it is brought up against a portion 
of peritoneum which has not been cut, then either the uterus or the 
peritoneal surface against which it is brought should be scarified. 
The early operators used silk, but to-day nearly all writers recommend 
the use of catgut. The chromatized or formalinized catgut is prefer- 



DISPLACEMENTS OF THE UTERUS 



307 



able, as it lasts longer and creates more irritation, and stronger adhesions 
are consequently formed. By bringing the posterior surface of the 
uterus in contact with the abdominal wall, intra-abdominal pressure is 
brought to bear upon the posterior surface in such a way that there is 
no tendency to a recurrence of the malposition. 

The indications for this operation, by either method, would seem 
to be limited to those cases in which pregnancy is impossible, and where 




Fig. 126 (Eedrawn from Kelly). — " Kelly inserts the sutures through the peritoneum and 
fascia in such fashion that when tied the knots are within the peritoneal cavity." — Mann 
(page 306). 

the abdomen is opened for some other purpose; also to cases of very 
severe prolapse with great relaxation, as already mentioned. "Where 
there is a possibility of pregnancy the operation should not be done, 
as a large number of cases have been reported where pregnancy and 
labour have been materially interfered with by the binding clown of 
the fundus uteri. 

Indirect Ventral Fixation. — Dr. A. H. Ferguson (Journal of the 
American Medical Association, November 18, 1899) describes a method 



308 



A TEXT-BOOK OF GYNECOLOGY 



of transplanting the round ligaments and attaching them to the abdomi- 
nal wall. After the usual preliminary antiseptic precautions, he opens 
the skin of the abdomen in the median line, the incision being three 
inches in length and beginning an inch and a half above the sym- 
physis. The linea alba 
and the anterior sheath 
of the recti muscles are 
exposed, and an incision 
is made on either side 
through the anterior 
sheath of the rectus. 
The rectus muscle is 
retracted outward, and 
an incision is made di- 
rectly behind it into 
the peritoneal cavity 
through the transversalis 
fascia and the perito- 
neum. 

Next, the round liga- 
ment and the portion of 
the broad ligament are 
seized by forceps one 
inch from the origin of 
the former at the inter- 
nal ring. These struc- 
tures are then tied, ex- 
ternally to the forceps, 
and divided (Fig. 127). 
The distal end of the 
round ligament is 
dropped into the peri- 
toneal cavity, and the 
proximal end is also 
pulled well out of the 
wound into it. The 
round ligament and its accompanying portion of the broad ligament 
are next sewed with catgut to the margins of the wound in the trans- 
versalis fascia and peritoneum (Fig. 128). The fibres of the rectus 
muscle are then replaced, and the opening in the anterior sheath 
closed with continuous catgut suture, which grasps the end of the 
round ligament. 

A similar operation is carried out upon the other side of the median 
line, and the incision closed. 

Dr. Ferguson claims in this way to get a firm support for the uterus, 
which is not adherent to the abdominal wall, but is suspended free in 
the pelvis and capable of motion. He reports twenty-two cases operated 




Fig. 127. — " Next [in Fergusson's operation], the round 
ligament and the portion of the broad ligament, 
are seized by forceps, one inch from the origin of the 
former . . . tied . . . and divided." — Mann. 



DISPLACEMENTS OF THE UTERUS 



309 



on in two and a half years, with ideal results. One of the patients be- 
came pregnant, and the pregnancy went on to normal termination. 

The indications for this operation are the same as for intra-abdomi- 
nal shortening of the round ligaments, for which it may be substituted. 

In comparing these various operations for the treatment of posterior 
displacements, it will be seen that each has its special indications, and 
no operator should become so attached to one method as to employ 
this to the neglect of the others. Alexander's operation unquestion- 
ably fulfils the indications in a large majority of simple cases. Where 
adhesions have occurred, 
if they are slight, they 
may be broken up 
through a vaginal inci- 
sion, and Alexander's 
operation done after- 
ward. 

In view of the excel- 
lent results obtained by 
Alexander's operation, 
the opening of the abdo- 
men for ventral fixation 
alone is scarcely war- 
ranted in simple cases. 
Where the abdomen is 
opened, and the tubes 
and ovaries left in such a 
condition that pregnancy 
may occur, then the in- 
tra-abdominal shortening 
of the round ligaments 
would seem to offer bet- 
ter chances of perma- 
nent cure without inter- 
ference with gestation. 

If serious disease of 
the tubes and ovaries ex- 
ists, then either the ab- 
domen must be opened or 
the vaginal operation 
done, as the operator may 
elect. For an operator 
with small experience, 

the abdominal operation unquestionably offers the fewer obstacles. For 
those skilled in vaginal work, the vaginal operation causes the woman 
the least trouble and annoyance from the operation. Where the abdo- 
men is opened for other cause, and pregnancy is rendered impossible, 
either by disease, age, or the operation, then ventral fixation would seem 




Fig. 128. — " The round ligament and its accompanying- 
portion of the broad ligament are next sewed with 
catgut to the margins of the wound in the transver- 
salis fascia and peritoneum." — Mann. 



310 A TEXT-BOOK OF GYNECOLOGY 

to be the simplest and easiest of performance, and to give promise of 
equally good results. Vaginal fixation has found little favour in this 
country, and, in view of the great difficulties encountered where preg- 
nancy has followed, should never be done in women liable to become 
pregnant. The tendency in this country, even among those who have 
been its advocates, seems to be to substitute some other form of opera- 
tion for it. 

Anterior Abdominal Cuneohysterectomy for Retroflexion of the 
Uterus. — In 1895 Eeed applied Thiriar's operation of cuneohysterectomy 
to the anterior wall of the uterus for the relief of retroflexion. Jonnesco 
made a similar adaptation of the operation in 1897. The technique 
does not differ in any essential particular from that described in the 
treatment of anterior displacements of the uterus, except that the site 
of operation is the anterior instead of the posterior wall. Eeed has 
done the operation but a very few times because the indications in 
retro-deviations generally are more effectively met by the operations 
upon the uterine ligaments, as described under another heading. The 
operation of anterior cuneohysterectomy is indicated only in those cases 
of retroflexion presenting marked hypertrophy with induration of 
the convex wall. When this condition exists, the removal of an ellip- 
tical segment is necessary to restore the organ to its normal axis. 

Jonnesco and Reed perform this operation in connection with 
shortening of the round ligaments. 

Ante-deviations. — The facts that the uterus occupies normally a 
position of anteversion and that there are no definite lines by which its 
normal position may be prescribed and limited, make it relatively diffi- 
cult to determine when an anterior displacement exists in a pathological 
degree. This is particularly true of anteversion; while the detection 
of a point of flexure in the axis of the uterus on its anterior surface is 
conclusive evidence of the existence of an anteflexion. 

The symptoms of forward displacements are pain in the sacral 
region with more or less vesical irritation and tenesmus; dysmenorrhea 
and sterility are usually present. The diagnosis is generally made 
without difficulty by bimanual examination. The fundus is felt to 
occupy a position anterior to its normal plane, the cervix generally 
pointing backward. If, with the patient lying upon her back, the 
finger is passed behind the cervix and the latter is drawn forward to- 
ward the pubis, the fundus will naturally be drawn upward and back- 
ward; and if, when the force is removed from the cervix, the uterus 
returns to the state of extreme anteversion, it may be known, not only 
that forward displacement exists to a pathological degree, but also 
that the anterior wall of the uterus is attached to the fundus of the 
bladder. The existence of a point of flexure on the anterior wall about 
the cervico-corporeal junction will establish the difference between 
anteversion and anteflexion. It should be remembered that a small 
subperitoneal fibroid on the anterior wall may feel like anteflexion — and 
the difference may not be detected without the use of the sound or an 



DISPLACEMENTS OF THE UTERUS 311 

abdominal section. The sound ought to be employed only under 
circumstances of exceptional importance. 

The pathology of ante-deviations, like that of other forms of dis- 
placement, is not confined to the uterus itself, but embraces a con- 
sideration of important changes in its suspensory apparatus. In the 
organ itself, however, in anteversion there frequently exists a condition 
of hyperplasia, and, occasionally, of neoplastic growth that makes the 
organ top-heavy, as it were, and acts as a potent cause in producing 
and maintaining a displacement. In other cases of anteversion paren- 
chymatous changes are sequent rather than causal. "When this devia- 
tion exists to such a degree as to interfere mechanically with the circu- 
lation — particularly on the venous side — more or less passive conges- 
tion of the organ results. This is expressed, not only in the gross 
enlargement of the uterus, but in the thickening and excessive epithe- 
lial growth of the endometrium. In anteflexion important structural 
changes are added to those already enumerated. If the angle of flexure 
is acute, atrophy of the uterine wall occurs at the point of angulation 
on the concave side, while hypertrophy is likely to occur on the con- 
vex side (Fig. 131). (See Pathology of Retro-deviations.) Contrac- 
tion of the utero-sacral ligaments, whether as a cause or as a conse- 
quence, generally exists in connection with forward displacements. It 
is probably a causative factor in many cases and one to be taken in 
account in the treatment. When the uterus is displaced forward in 
an extreme degree, the fundus of the uterus riding upon the fundus of 
the bladder, adhesion of the proximal peritoneal surfaces is liable to 
occur, particularly in the presence of infectious inflammatory condi- 
tions within the pelvis. When this complication exists, there is always 
more or less inflammatory mischief in the wall of the bladder. Ex- 
treme ante-deviations imply more or less constant tension on the broad 
ligaments, which, sooner or later yielding to this influence, become 
relaxed and cease to exercise their function of holding the uterus in 
its natural poise. 

The treatment of forward displacements of the uterus, aside from 
surgical measures, has been unsatisfactory. Pessaries, while occasion- 
ally affording temporary relief, have more frequently caused discomfort 
and damage. Graily Hewitt's cradle pessary at one time had a con- 
siderable vogue, but it, like its congeners, is now generally abandoned. 
The judicious use of tampons has been attended with comfort and fol- 
lowed by substantial improvement. When acute pain exists with for- 
ward displacements the patient should go to bed, take a laxative, and 
be given frequently repeated hot douches, with occasional glycerine 
tampons. A case that can be controlled by a pessary can, in all proba- 
bility, be relieved with equal efficiency and greater comfort by the 
measures just enumerated. When, however, in spite of careful atten- 
tion to the details given, forward displacements exist to such a de- 
gree as to interfere with health, recourse should be had to surgical 
treatment. 



312 



A TEXT-BOOK OF GYNECOLOGY 



Forward displacements of the pregnant uterus occur either by re- 
laxation of the abdominal wall or by a ventral hernia. Sometimes the 
entire gravid uterus occupies a large hernial sac (Fig. 129). A sup- 
port should be furnished to the protruding mass until delivery lessens 
its volume and renders it reducible. The case after this period is to be 

recognised and treated as 
one of ventral hernia. 

The surgical treatment 
of forward displacements 
has as yet embraced no 
operation for anteversion 
of the uterus. Where that 
condition is due to retrac- 
tion and shortening of 
the utero-sacral ligaments 
pulling the cervix upward 
and backward, and thus 
throwing the fundus too 
far forward, it has been 
proposed to cut through 
the posterior vaginal wall 
and resect the ligaments, 
thus allowing the cervix 
to come forward and as- 
sume a more normal posi- 
tion. This operation is 
rarely necessary. 

It has also been pro- 
posed to do Alexander's 
operation in these cases, 
and to raise the fundus by the round ligaments. As the round liga- 
ments were never made for this purpose, it is not likely that the opera- 
tion would be permanently successful. At any rate, these operations 
have never achieved a position in gynecological surgery, and are rarely 
even mentioned in literature. 

A history of the operations which have been devised for the cure 
of pathologic anteflexion would form a very interesting chapter. From 
the operations of Simpson, Sims, and Peaslee, down to the present time, 
very many operations have been devised, all having for their object the 
straightening of the uterine canal. The earlier operations of Sims were 
not successful, owing, however, largely to the conditions in which they 
were done — the want of a proper aseptic technique. The later opera- 
tions which have been done have been much more successful and satis- 
factory. The majority of operators, however, are content with the 
operation of forcible dilatation, usually conjoined with curetting. 

Dilatation and Curetting. — This was suggested by Dr. John Ball, 
of Brooklyn, in 1877 (New York Medical Journal, vol. xviii, p. 363). 




Fig. 129. — "Sometimes the entire gravid uterus occu- 
pies a large hernial sac." — Reed. 



DISPLACEMENTS OF THE UTERUS 313 

Ellinger did a similar operation, and Goodell modified Ellinger's dilator 
and followed Ball's method, and was the first to popularize it in this 
country. Hanks also operated about the same time, using graduated 
dilators instead of the expanding dilators of the other operators. That 
dilatation is better than cutting is now generally admitted, and the 
large number of good results which have followed it has made this 
one of the most beneficent operations in gynecological surgery. That 
it cures the flexion is not asserted by its most ardent supporters; but 
that the flexion is benefited and the symptoms relieved, is, in the major- 
ity of cases, generally admitted. 

This operation is indicated in any uncomplicated case of anteflexion 
where the flexion seems to be productive of symptoms. There is usu- 
ally present an endometritis, and this has more to do with the symp- 
toms than the flexion, and is, in turn, largely the result of the flexion. 
The operation has in view, not so much the cure of the flexion, as the 
relief of the complication — that is, the endometritis. 

Technique. — The patient being anaesthetized and placed upon the 
table, with the hips overhanging the edge and the thighs held in place 
by suitable legholders or assistants, the vagina is thoroughly scoured 
with gauze and green soap. The advisability of this procedure has 
been doubted by some, as it is a well-known fact that the normal vagina 
is aseptic. While this is generally admitted, it is not true in morbid 
conditions; and, as we can hardly make a complete bacteriological in- 
vestigation in every case, it is better to be upon the safe side and 
thoroughly to wash out and disinfect the vagina. After the scrubbing 
with the green soap, the vagina should be washed with a solution of 
bichloride (1 to 3,000). An Edebohls's or Jones's speculum is then 
introduced, and the cervix seized with the traction forceps and pulled 
down toward the vulva. After the direction of the cervical canal has 
been carefully made out by the uterine sound, a small uterine dilator 
(Hanks's or Palmer's) is introduced, and sufficient dilatation effected 
to admit the introduction of the Ellinger-Goodell dilator. "With 
this the cervix may be forced open, at least up to the inch and a quar- 
ter mark upon the index. A few minutes should be allowed for this, 
as the uterus is sometimes very friable, and too rapid dilatation may 
tear the tissues. "When the dilatation is complete, the uterus should 
be washed out with the bichloride solution, and then thoroughly 
curetted with the Sims sharp steel curette. After this, it is again 
washed, and packed with iodoform gauze. 

Some operators, instead of packing with gauze, prefer to introduce 
a large stem pessary, half an inch in diameter, and then to pack the 
upper part of the vagina around the stem with iodoform gauze. 

If the cavity of the uterus has been packed with gauze, the gauze 
may be removed on the fourth day, or sooner if it causes too much 
pain. If the glass stem has been introduced, upon the fifth day the 
stem should be withdrawn, the interior of the uterus carefully washed 
out with peroxide of hydrogen, and mopped out with a 5-per-cent 



314 A TEXT-BOOK OF GYNECOLOGY 

solution of ichthyol and glycerine. The stem should then be reintro- 
duced, and a tampon of cotton or iodoform gauze put in, to keep it in 
place. This procedure should be carried out daily until all the tender- 
ness upon the interior of the uterus has disappeared. 

The patient should be kept in bed for four days, though she may 
be allowed to sit upon the commode for the purpose of emptying the 
bladder and bowels. After this, she may be up and dressed, and gradu- 
ally resume her ordinary mode of life. 

In this way a very large proportion of cases will be relieved, not 
always of the anteflexion, but of the symptoms to which the anteflexion 
has given rise. 

Dudley's Operation. — Dr. E. C. Dudley, of Chicago {Diseases of 
Women, 1898), recommends an operation for anteflexion which has for 
its object, not only the curing of the endometritis, but also the com- 
plete correction of the deformity. Mann has had some experience 
with this operation, and has been entirely satisfied with the results,, 
although his cases have not been numerous enough to enable him to 
speak with a great deal of positiveness. Dudley, however, recom- 
mends the operation, and it certainly accomplishes what he claims for 
it — namely, the complete rectification of the displacement. 

Technique. — The operation is done as follows: The patient is placed 
in Sims's position, and the speculum is introduced under ether. The 
uterus is then dilated and curetted in the usual manner. The cervix 
is divided with scissors, backward in the median line, past the utero- 
vaginal attachment, nearly to the utero-peritoneal fold, in the pouch 
of Douglas (Fig. 381, Dudley). 

" The cut surfaces thus incised are then held widely apart by means 
of two tenacula in the hands of an assistant; the incision is somewhat 
deepened by means of a scalpel, especially in the uterine wall next to 
the cervical canal, and a small angle is cut out on either side, as shown 
by the dotted lines in Fig. 382. The cut surface on each side is 
now folded on itself by a single silkworm gut suture, as shown in Fig. 
382. This suture is tied and fortified by interrupted sutures on either 
side. The lines of union thus made are shown in Fig. 383. 

" These sutures are not introduced in such a manner as to stitch 
the intracervical to the vaginal margin of the wound, but the cut 
surface is folded upon itself in a direction at right angles to this. On 
either side, that point at the margin of the os externum where the back- 
ward incision commenced is stitched to the very angle of the incision, 
so that each cut surface is folded upon itself, not from within outward, 
but from before backward. Thereby the os externum is carried di- 
rectly back to the angle of the incision. The cervix now points back- 
ward in its normal direction toward the hollow of the sacrum, instead 
of forward toward the vaginal outlet (see Fig. 383). 

" In some cases of extreme anteflexion, there is a disproportionately 
long anterior lip. This elongation is shown by the dotted line in 
Fig. 377. It is the result of a relatively greater pressure on the 



DISPLACEMENTS OF THE UTERUS 315 

posterior lip by the posterior vaginal wall; this lip should be caught 
with the tenaculum and partially removed by the scissors. The incised 
surface is then closed upon itself with sutures as shown in Fig. 384. 
The dotted line in Fig. 377 shows in section the line of incision through 
the protruding lip; the incision should extend to, but not into, the 
os externum. This part of the operation is not required unless the 
anterior lip decidedly protrudes, and is therefore usually omitted. The 
removal of a portion of the lip in a suitable case is not only not a 
mutilation, but it even contributes to the straightening of the 
uterus. 

" Conjoined examination upon completion of the operation in each 
of the author's cases has invariably shown the uterus either to have 
been straightened or the anteflexion to have been reduced to a degree 
quite within physiological limits. The results have been substantially 
the same whether the point of flexure was at the os internum or be- 
low it. 

" The two posterior lines of sutures have the effect of transplanting 
the os externum to the very angle of the posterior incision. The an- 
terior sutures, if used, have the effect of carrying the cervix back by 
a distance equal to one half the length of the anterior cut surface, 
which is doubled upon itself. By these means a permanent change, 
quite equal to overcoming the flexure, is effected in the direction of 
the cervix. As the result of the anterior portion of the operation, the 
uterus in a suitable case is lifted also in a higher plane in the pelvis, 
where it ceases to be a mechanical irritant to the bladder. This por- 
tion of the operation may therefore be indicated for descent when 
complicated with anteflexion." (Dudley, Diseases of Women, p. 
581, etc.) 

This operation is not a substitute for dilatation and curetting, but 
rather supplementary thereto. 

An operation called cuneoliysterectomij has been devised for the 
cure of anteflexion. It is done by abdominal section and consists in 
removing a cuneiform piece of tissue from the convex side of the 
uterus at the point of angle. Its object is to straighten the anteflexed 
uterus by reducing to normal dimensions its elongated posterior wall. 
When done on the posterior wall it is called posterior cuneohysterec- 
tomy, and vice versa. The procedure was devised and practised by 
Thiriar in 1892. Eeed did it for the first time in 1894. The details 
of the operation, as he has modified and now practises it, are as fol- 
lows: The patient is prepared with the usual aseptic and other pre- 
cautions for abdominal section. An incision about 12 centimetres 
in length is made in the median line and is carried as low as practicable 
with safety to the bladder. The patient is now placed in the Trende- 
lenburg position. All adhesions between the uterus and bladder or 
between the uterus and other organs are carefully broken up, and 
rents in the serosa that may be induced thereby are carefully stitched. 
The uterus is then brought toward the incision by gentle but firm 



316 



A TEXT-BOOK OF GYNECOLOGY 















■L •'"■ % 




T 




HUMS 











Fig. 130. — ". . . an ellipse of tissue about one centimetre 
wide, and having a length corresponding to the breadth 
of the organ, is removed from the convex side at the site 
of flexure.' 1 — Keed. 



traction and an ellipse of tissue about 1 centimetre wide, and hav- 
ing a length corresponding to the breath of the organ, is removed 

from the convex side 
of the site of flexure 
(Fig. 130). Care must 
be taken not to carry 
this dissection into 
the cavity of the 
uterus (Fig. 131), 
or to wound either 
the circular artery 
or the anastomosing 
branches of the uter- 
ine arteries. Should 
the latter accident 
occur, its result is 
best counteracted by 
ligatures en masse passed deeply into the uterine tissue at either end 
of the yet gaping ellipse. Retraction of the vessels generally prevents 
their isolation and closure 
by direct ligature which, 
when practicable, is al- 
ways the preferable meth- 
od. After all hemorrhage, 
except mere capillary ooz- 
ing, is controlled, the 
margins of the ellipse 
should be carefully ap- 
proximated and closed by 
an interrupted suture, or 
a continuous animal su- 
ture fortified with two or 
three interrupted ones of 
the same material. The 
uterus is then dropped 
back, and, after pausing 
a moment to make sure of 
complete hemostasis, the 
abdomen is closed with- 
out drainage. A further 
modification of this op- 
eration, and one which 
Reed has practised with 
satisfaction, consists in 
stitching a reef of the 
posterior folds of the 
broad ligament to either 




Fig. 



131. — "Care must be taken not to carry this dis- 
section into the cavity of the uterus." — Keed. 



DISPLACEMENTS OF THE UTERUS 



317 



side of the posterior surface of the uterus (Fig. 132). The utero- 
sacral ligaments, if found contracted, are nicked and stretched. He 
has been able by these combined methods to relieve the most dis- 
tressing and persistent symptoms, vesical, uterine, ovarian, and neuro- 
tic, due to otherwise 
intractable anteflex- 
ion of the womb. 

Prolapsus Uteri. 
— Prolapsus is that 
anomaly of position 
of the uterus in which 
the organ has shifted 
from its normal site, 
has descended or fall- 
en to a lower level, 
and projects partly 

or completely outside of the vulva (Fig. 133). According to the degree 
of the descent we distinguish between partial or total prolapse. There is 
only a difference in degree between these varieties, their entire etiology 




Fig. 132. — " A further modification . . . consists in stitch- 
ing a reef of the posterior folds of the broad ligament to 
either side of the posterior surface of the uterus." — Reed. 



HS^ 




«3HfiPS&S 



133. — "Prolapsus is that anomaly of position in which the uterus projects partly or 
completely outside the vulva."— Herzog. 



being the same, and they do not call for a separate consideration. Par- 
tial prolapse is frequently spoken of as descensus uteri; the term pro- 
lapsus is then reserved for the total prolapse. 



318 A TEXT-BOOK OF GYNECOLOGY 

Prolapsus uteri is almost invariably an acquired condition, though 
there have been reported by Ballantyne and Thomson, Heil, Krause, 
and Kemy and Quisling, a few cases of congenital prolapse. These 
cases were always found in connection with other congenital anoma- 
lies. A condition simulating partial prolapse, which, however, anatom- 
ically, as well as from an etiological point of view, is entirely different 
from the morbid condition under discussion, is that of primary hyper- 
trophy of the portio vaginalis uteri. This anomaly is always congeni- 
tal, and it may and does secondarily lead to a true prolapse. 

There exists still a good deal of controversy as to the etiology and 
mechanism of prolapsus. A view formerly held almost universally, 
and still adhered to by some, is that the primary factor in the produc- 
tion of a prolapse of the uterus is the prolapse of the vagina. The 
latter again is traced back to a subinvolution during the puerpefium. 
This opinion is contested by Kustner, who has studied the subject 
extensively and who very clearly and forcibly elaborates his observa- 
tions and views in a most excellent treatise (Veit's Handbuch der 
GyndJcologie, Wiesbaden, 1897, vol. i, p. 168). This author holds 
that it is impossible that a uterus normal in position can be forced 
out of the pelvis into the vagina. As long as the uterus is in its 
normal antero-versio-nexio position abdominal pressure acts upon 
its posterior wall and presses the body upon the bladder. The portio 
vaginalis under increased abdominal pressure has a tendency to 
rise, if anything. When, however, the uterus is in a retroverted- 
retroflexed position its vaginal portion becomes dislocated in the 
direction of the symphysis pubis and moves at the same time nearer 
the pelvic outlet. The uterus and its cervix now lie so that their 
axis has the same direction with, or forms the continuation of, the 
axis of the vagina. Increased intra-abdominal pressure can now 
easily force down the uterus into the vagina, this being made still 
easier since in retro-versio-flexio the vaginal portion of the cervix 
is nearer the pelvic outlet than under normal conditions. It is quite 
common that a history of retro-versio-flexio can be obtained in cases 
of prolapsus. The reason this condition is most frequently found 
among women in the lower walks of life is easily explained. Women 
of the better classes, as a rule, when retro-versio-flexio leads to any 
symptoms, seek medical aid and receive the proper attention. Women 
who have to work hard for a living often find no time to consult 
the physician, and, even if they do, they can not submit to the proper 
treatment and regimen to correct the retro-versio-flexio. If this 
goes on uncorrected and the woman suffering from it is performing 
hard physical work, the constant exertions, and the persistent abdom- 
inal strain in consequence thereof, will, in a large percentage of cases, 
force down the uterus and produce descensus and prolapsus. There 
are also some cases, however, in which the causation of the affection 
may be different. If, after childbirth, the vulva remains gaping for 
too long a time, there may occur a prolapse of the anterior vaginal 



DISPLACEMENTS OF THE UTERUS 319 

wall, even if the uterus is not in retro-versio-flexio, and this may be 
followed by prolapse induced by the persistent traction upon the 
uterus and its ligaments. Prolapse may be preceded and caused by 
extensive untreated perineal lacerations, the mechanism of causation 
being the same as just indicated. Another set of conditions which 
may bring about prolapse is senile changes of the genitalia, accom- 
panied by atrophy of muscular, and disappearance of adipose, tissue. 
A factor which may greatly hasten the establishment of an extensive 
prolapse, if the other conditions are favourable, is great increase in the 
intra-abdominal pressure in consequence of large pelvic tumours or 
ascitic accumulations. In prolapse of the uterus there is, of course, 
present a prolapse of the vagina. The upper part of the latter is either 
invaginated into the lower part, or the whole of the vagina lies inverted 
in front of the vulva. Total prolapsus uteri, however, does not always 
mean total prolapse of the vagina, and vice versa. Combined with 
the uterine prolapse, there is present a displacement of the bladder 
(cystocele), and of the urethra. Eectocele may be present but is usu- 
ally absent. 

The pathologic changes are various. That such a malposition, such 
a complete change of conditions as is found in prolapsus uteri, is 
accompanied by grave and profound anatomical lesions, is self-evident, 
though of course some of the pathologic changes precede instead of 
follow descensus. Very marked are the changes of the lining of 
the inverted vagina. The epithelia become dry and horny. In some 
places the epithelial covering is thickened, while in others, particularly 
in the neighbourhood of the external os of the cervix, it becomes 
thinned out and is entirely lost, so that ulcerations appear in this 
neighborhood. These changes are due to the fact that the inverted 
vagina is no longer moistened by the cervical secretion but is exposed 
to the air and subjected to other insults. The ulcerations frequently 
show sharp margins, or they present clefts caused by traction upon 
the changed tissues. There is generally noticeable a hypertrophy of 
the prolapsed parts. It is most marked at the portio vaginalis uteri, 
but is also well seen in the supravaginal portion. The cervix as a 
whole is often greatly elongated and thickened in its anteroposterior 
and lateral diameters (Fig. 134). The uterine body is likewise en- 
larged, though proportionately to a lesser degree. In women advanced 
in years, the enlargement of the corpus may be very insignificant or 
even absent. The enlargement of the uterus is, however, not so 
much due to a true hypertrophy as to an extensive oedema caused by 
circulatory disturbances. That this is indeed the case, is proved by 
the observation that after reposition of the organ, its size is often ma- 
terially decreased in a very short time. The mucous membrane of the 
uterus in prolapse is thick and succulent, and there occurs not infre- 
quentty an endometritis glandularis hypertrophica. The higher de- 
grees of prolapse being usually combined with prolapse of the bladder, 
this organ likewise shows morbid changes, such as catarrhal inflam- 



320 



A TEXT-BOOK OF GYNECOLOGY 



mation of the vesical mucous membrane, or inflammation of the muscu- 
lar coat which may even lead to destructive processes. The vesical 
inflammation may spread by continuity to the ureters and the pelves 
of the kidneys. Kustner in a case of prolapsus uteri saw a profound 

purulent pyelitis 
which ran a fatal 
course. Inflamma- 
tory changes of the 
internal sexual or- 
gans, the tubes and 
ovaries, and the 
pelvic peritoneum, 
are quite frequent in 
prolapse. Kustner, 
in a series of eighty 
cases of laparoto- 
mies, ventrofixa- 
tions, and plastic 
operations on the 
vagina for prolapse, 
carefully examined 
the internal sexual 
organs and found 
that in almost one 
half of them chron- 
ic inflammatory pro- 
cesses could be ob- 
served in the ova- 
ries, the pelvic 
peritoneum, and the 
fimbriated extremi- 
ties of the Fallopian 
tubes. The patho- 
logic conditions 
found were oophori- 
tis corticalis, hy- 
drops folliculorum 
ovarii, perimetritis, 
perisalpingitis with 
or without closure 
of the abdominal end of the tube, and hydrops of the tubes. The same 
author frequently noticed a mild degree of serous infiltration of the pel- 
vic peritoneum. In some of his fatal cases of prolapse he saw, in conse- 
quence of profound septic infection due to streptococci, abscess forma- 
tion in the subperitoneal connective tissue, particularly in the con- 
nective tissue between the bladder and uterus. Also purulent infil- 
tration of the muscular coat of the uterus, abscess of the ovary and 




Fig. 134 (Martin). — " The cervix as a whole is often greatly 
elongated and thickened in its antero-posterior and lateral 
diameters." — Herzog (page 319). 



- 



DISPLACEMENTS OF THE UTERUS 321 

encapsulated or general purulent peritonitis. (See Pathology of Uter- 
ine Displacements.) 

The symptoms of prolapsus uteri may be so mild in the earlier 
stages as easily to escape attention, or, if detected, they are liable to 
be interpreted as indicating a less important condition than a displace- 
ment of the uterus. Pain in the loins, sacralgia, increased by walking, 
prolonged standing or overhead work, and, particularly by straining at 
defecation, is the first to attract attention. This pain increases as 
the condition advances until the patient becomes conscious of what 
she construes to be a foreign body in the vagina. Pressure by the 
descending organ is liable to cause vesical and rectal tenesmus. In a 
still further stage of development the cervix presents at the ostium 
vaginae, or the entire uterus may protrude externally and occupy a 
position between the thighs. The diagnosis in the earlier stages is 
not always easily made. Patients are generally examined in either the 
recumbent or the semiprone (Sims's) position — in either of which, but 
particularly in the latter, a uterus in the earlier stages of descent has 
a tendency to gravitate into its normal situation. It occasionally hap- 
pens that the first suggestion of an existing prolapse is derived from 
the fact that a well-adjusted tampon is being unaccountably extruded 
from the vagina. This fact will prompt an examination of the patient 
in the standing posture — provided that this has not already been done, 
as a part of the earlier examination of the case. The uterus will be 
found to have descended from its normal plane and to occupy a posi- 
tion of relative retroversion. It may be found in any degree of de- 
scent. Complete procidentia may be mistaken by the patient herself 
for cystocele and hydrocele, but this point is easily cleared up by care- 
ful examination. A uterine polypus, or even one of vaginal origin, 
may simulate complete procidentia uteri. The diagnosis is cleared up 
under these circumstances by careful digital examination, with par- 
ticular reference to detecting the location and condition of the cervix. 
Bimanual exploration, by determining the location of the fundus and 
the size of the uterus, will clear up any remaining doubts. Inversion 
has been mistaken for prolapsus of the uterus, but the history of the 
case, the existence of the hemorrhage, the character of the mucosa, and 
the existence or nonexistence of the fundus in its normal relations as 
determined by bimanual examination, will lead to an accurate con- 
clusion. 

Treatment. — Conservative, or, more properly speaking, the nonsurgi- 
cal treatment of these cases, resolves itself into medicinal, hygienic, and 
mechanical. The medicinal treatment consists, for the most part, in 
the administration of laxatives to overcome the constipation, which, in 
many cases, is a potent factor in the causation of the trouble. For this 
purpose saline waters, such as the Hunyadi Janos or the Apenta, should 
be given persistently in comparatively small doses after, but not be- 
fore, meals. If given before meals, they will cause catharsis, enerva- 
tion of the bowels, and consequent aggravation of the constipation; 
22 



322 A TEXT-BOOK OF GYNECOLOGY 

but if given after meals they will mingle with the food, and, after a. 
couple of days, induce normal dejections not followed by serious conse- 
quences. Hygienic measures consist in attention to all the secretory 
functions, and especially avoidance of errors in diet. Massage of the 
uterus has been recommended, and as a remedy for relieving passive 
engorgement or chronic hyperplasia it is of value, and should be 
employed for the relief of prolapse, especially in its incipiency, when- 
ever dependent upon these conditions. It should not, however, be 
employed in the presence of acute inflammation of either the uterus or 
its appendages. Under the head of mechanical treatment tamponade 
must be given first place. This should be practised as elsewhere de- 
scribed in this volume. If tampons saturated with some astringent 
agent are carefully adjusted they will give excellent mechanical sup- 
port and afford the relaxed ligaments an opportunity to regain their 
strength. Pessaries are employed for the same purpose and a certain 
percentage of cures is realized from their employment, which, how- 
ever, is not destitute of danger. The pessary with an intrauterine stem 
should never be employed; cup-pessaries are for the most part mis- 
chievous in their results, and, to avoid their damaging influence, must 
be frequently removed. The martingale ring of hard rubber may keep 
the uterus within the pelvis, but it does so by distending the vagina 
laterally and by resting upon the pelvic floor. The inflated soft-rubber 
pessary has an even better power of retention, but it is, at best, a dirty 
and stinking thing, and should be used only when other means of 
treatment are not available. This instrument is very popular with 
practitioners because of the facility with which it is placed and the 
effectiveness with which it keeps the womb from dropping out of the 
vulvar orifice. The fact, however, is generally lost sight of, that this 
pessary never cures prolapsus in the sense of restoring the uterus to 
its normal position and keeping it there, and but few practitioners 
take into account the other fact, namely, that by a continuous pressure 
upon the pelvic floor and by persistent lateral distention of the vagina, 
this instrument has a tendency really to aggravate pre-existing 
troubles, notwithstanding the fact that it affords temporary relief. 
The soft-rubber pessary favours germ propagation and is, therefore, a 
constant menace to the health. The best device among pessaries is 
Thomas's retroversion pessary already alluded to. If carefully ad- 
justed, it affords comfort in these cases and its use is sometimes fol- 
lowed by cure. 

The surgical treatment of downward displacements of the uterus 
has for its object the return of the organ to its natural position and 
its retention there by the restoration, so far as possible, of its normal 
anatomic connections. Any treatment, to be effective, must be carried 
out in full recognition of the fact, that prolapse of the uterus commonly 
occurs as the result of either serious lacerations of the pelvic floor and 
the perineum, or as the result of atrophy and relaxation of all the 
uterine supports. The final result is the same in each case. In a 



DISPLACEMENTS OF THE UTERUS 323 

limited number of cases, the injuries below are not so much the cause 
of the prolapse as the great relaxation of the uterine ligaments, particu- 
larly the utero-sacral. No prolapse can take place without relaxation 
of these ligaments. 

The first step in a prolapse is always a retroversion; so that relaxa- 
tion of the round ligaments is a universal accompaniment of this con- 
dition. If, with the relaxation of the round ligaments, there is also 
relaxation of the utero-sacral ligaments, then the uterus, following the 
axis of the pelvis, slowly and gradually makes its way downward under 
the influence of intra-abdominal pressure, until it finally appears at 
the vulvar orifice, and may eventually be forced outside the patient's 
body. These being the causes of prolapse, all operative procedures 
must have for their object the restoration of the normal supports of 
the body. If these can not be restored, then some new support must 
be sought. With the object of relieving the downward traction on 
the uterus, operations may be performed on both the anterior and pos- 
terior vaginal walls. Unquestionably, the best operations for this 
purpose are those devised by Sims and Emmet. 

Emmet's Operation upon the Anterior Vaginal Wall (Anterior Col- 
porrhaphy). — " I first ante vert the uterus with my finger, as the patient 
lies on the back. The neck of the uterus is then kept crowded up 
into the posterior cul-de-sac by a sponge probang in the hands of an 
assistant, while the patient is being placed on the left side for the intro- 
duction of the speculum. I then endeavour to find two points, one 
about half an inch from the cervix on each side, and a little behind 
the line of its anterior lip, which can be drawn together in front of the 
uterus by means of a tenaculum in each hand. When two such points 
can be thus brought together without undue tension, forming trian- 
gular-shaped folds, the surfaces are to be freshened. One of the te- 
nacula must be securely hooked in the tissues, to indicate the point. 
Then, one hand being disengaged, a surface half an inch square about 
the point of the other tenaculum is to be denuded with a pair of 
scissors. Next a similar surface is to be freshened around the point of 
the first tenaculum, and a strip afterward removed from the vaginal 
surface, in front of the uterus, about an inch long by half an inch 
wide." (Emmet's Gynecology, third edition.) 

A ligature of catgut is then passed beneath each of these freshened 
surfaces, which, when tied, brings them all together in front of the 
cervix, with the effect of forming a fold at this point. There are 
also, upon the anterior vaginal wall, tAvo folds in the shape of an 
ellipse, extending from the surfaces secured in front of the uterus, 
nearly to the vaginal outlet. These folds are now to be denuded, 
turned in, and secured with a continuous catgut suture. The stitches 
should be placed about a quarter of an inch apart, and should include 
a liberal amount of tissues. The patient should be confined in a re- 
cumbent position for two or three weeks after the operation, until the 
parts are firmly united. 



324: A TEXT-BOOK OF GYNECOLOGY 

Following this operation, or at the same sitting if thought advisable, 
the perineum should be firmly closed by Emmet's method. (See Chap- 
ter on Rupture of the Perineum.) 

The cervix uteri, if lacerated or diseased, should be closed by the 
operation of trachelorrhaphy, or amputated, as the case may be. 

It is Mann's belief that these operations alone will not generally 
cure permanently a bad case of prolapse. As the uterus is always 
retroverted in this condition, if it is left turned back it will remain in 
the axis of the vagina, and, acting as a wedge, will gradually force its 
way down and out, and the old conditions will be reproduced. To ob- 
viate this condition, it will be necessary to restore the round ligaments 
and the utero-sacral ligaments. In this way the cervix can be kept 
up in the hollow of the sacrum and the fundus turned forward. If 
this is done, the uterus will be at nearly right angles to the vagina, 
and the danger of a return of the prolapse will be done away with. 

After the operations upon the vaginal outlet the patient may wear 
a pessary, which takes the place of the utero-sacral ligaments, and 
this in itself may be enough. If not, then Alexander's operation may 
be done and the fundus kept forward by the tightened round ligaments. 
All idea of curing a prolapse by doing Alexander's operation must be 
laid aside, as the round ligaments alone are not strong enough to sus- 
pend the uterus, but, in a very short time, will give way and allow a 
relapse. In very bad cases where the uterus is greatly enlarged, and 
in old women, in whom very great atrophy of the parts has taken place, 
all these procedures are apt to fail, and we must then resort to ventral 
fixation, as already suggested. 

The removal of the uterus for the cure of prolapse, in the opinion 
of Mann and other representative gynecologists, is wrong. It is not, 
in his view, the weight of the uterus merely which brings it down, but 
the relaxation of the supporting structures. After the uterus is re- 
moved, the vaginal walls will come down as badly as ever, and Mann 
has seen one case at least in which hysterectomy failed to cure, the 
previously existing rectocele and cystocele recurring and becoming 
worse, until a complete hernia of the vagina existed. The cure of this 
condition is exceedingly difficult, and is harder than before removal 
of the uterus, as the possibility of ventral fixation is done away with. 

Inversion of the Uterus. — Inversion of the uterus means a turning 
inside out of that organ, and consists of the invagination of the fundus 
into or through the cavity of the womb. This form of displacement is 
not frequent; Braun and Spaeth report that not a case of complete 
inversion of the uterus has occurred in 250,000 births in their clinics; 
while it has been observed but once in 191,000 deliveries in the Eo- 
tunda Lying-in-Hospital of Dublin. 

The causes of inversion of the uterus are generally, but not always, 
connected with parturition. At this time, when the uterus is enlarged 
and its walls are softened by the ordinary evolutional changes of preg- 
nancy, but two additional conditions are required to render inversion 



Tl 



DISPLACEMENTS OF THE UTERUS 325 

probable, viz.: relaxation of the uterine wall and downward traction 
upon the fundus. This traction may be exercised by drawing upon 
the cord in a case of fundal implantation of the placenta; or, given a 
case of adherent fundal placenta, the involuntary efforts of the uterus 
to expel the afterbirth, may cause the latter to drag the fundus down- 
ward into the cavity, or, for that matter, through the open cervix into 
the vagina. A large pedunculated polypus attached to the fundus of 
the uterus and finally expelled by that organ may, by persistent trac- 
tion, induce inversion in the nonpregnant uterus. A case of this 
kind came under the observation of Eeed. Small sessile fibroids have 
been found in the wall of the inverted uterus and have been construed 
as causes of the condition. The mechanism of inversion in these cases 
has been explained by Treub, who states (British Gynecological Journal) 
that in them there " is no regular contraction of the uterine wall and 
that there can not be. The base of a sessile tumour can not contract, 
because of the implantation of the tumour, which diminishes or alto- 
gether abolishes the contractility of that part of the wall, and it can 
not be that only the contractility of that base is diminished; the sur- 
rounding parts must necessarily be feebler within a greater or smaller 
circumference. If from the outset the tumour was intramural, the 
smaller degree of resistance of that part of the uterine wall, coupled 
with intra-abdominal pressure, may occasionally bring about a slight 
beginning of inversion. And when this is the case, the conditions 
are essentially the same for sessile and intramural tumours, and for the 
partial inversion described by Rokitansky. A circle of uterine tissue 
is abruptly curved in the place where Rokitansky found the external 
indentation. I need hardly say that in that incurved circle the uterine 
muscle must be absolutely paralyzed. And this paralysis again will not 
be confined to a linear circle, but gradually diminishing will extend 
over a greater or smaller surface. The contractions of the normal part 
of the uterine wall will try to expel the part of the wall that acts as a 
foreign body. These expulsive efforts may slightly increase the inver- 
sion as far as the paralysis surrounding the circle of inversion permits, 
thus displacing the circle itself; and paralyzing another part of the 
uterine wall. Necessarily the extension of the partial paralysis proceeds 
farther in the uterine wall, too, and by the repeated action of this mus- 
cular play the inversion may gradually become complete as regards the 
body of the uterus. As soon as the body is inverted, there is no longer 
any excitement for uterine contractions, and the inversion of the cervix 
generally does not take place. And it is the intra-abdominal pressure 
again that may invert the cervix too." 

Inversion of the uterus may be complete or incomplete; in the for- 
mer case the organ is turned completely inside out, the inverted fundus 
and body of the uterus lying within the vagina (Fig. 135), or protruding 
from the vulvar orifice. The condition may also be described as recent 
or old, acute or chronic, the one type being represented by the recent 
inversion of the organ with its attendant alarming symptoms; the 



326 



A TEXT-BOOK OF GYNECOLOGY 



other, when the condition either complete or incomplete has occurred, 
involution of the uterus having taken place after the occurrence of 
the displacement, which remains in a chronic and more or less perma- 
nent form. 

The symptoms of inversion of the uterus following parturition con- 
sist, first, in profuse hemorrhage ensuing upon the delivery of the 
placenta; or, when the fundus is drawn down by the still adhering 

placenta the latter 
may be peeled off by 
external action, and 
violent hemorrhage 
ensue. Physical ex- 
amination should be 
made at once by the 
bimanual method. 
The intra - vaginal 
finger will detect a 
globular mass, pre- 
senting either just 
without or just with- 
in the thoroughly re- 
laxed cervix; while 
the hand upon the 
abdominal wall will 
readily detect the 
disappearance of the 
fundus from its nor- 
mal site with the 
development of a dis- 
tinct ring at the 
point of its disap- 
pearance. In an in- 
teresting case reported by Cordier wherein an inversion had fol- 
lowed an operation for the removal of a polypus, the symptoms during 
the next few months were those of frequent yet slight discharge of 
blood-stained fluid from the vagina; there were no menstrual pains, 
nor was there a histoiy of extrusive contractions of the uterus. 
Digital examination revealed in the vagina a pyriform mass about 3 
inches in length by 2.5 in breadth, of a soft and velvety nature, and 
not painful to the touch. The finger could be carried all round 
the mass, which disappeared through the os by a constricted neck, and 
could be swept around the neck of the mass for nearly an inch within 
the cervical canal. The speculum revealed the openings of the Fallo- 
pian tubes, on the presenting aspect of the mass. A probe could be 
easily introduced into the uterine ends of the tubes under vision while 
the speculum was in position. Such appearances as the foregoing, 
coupled with the disappearance of the fundus from its normal situa- 




Fig. 135. — " Inversion of the uterus may be complete . . . 
the . . . fundus and body . . . lying within the vagina." 
— Keed (page 325). 



DISPLACEMENTS OF THE UTERUS 327 

tion, as determined by bimanual exploration, comprise the essential 
diagnostic criteria in these cases. 

If the abdominal wall is thick, and the condition of the uterus, 
particularly in nonparturient or in chronic cases, can not be outlined 
by the bimanual manipulation, the index finger of one hand should 
be introduced into the rectum while a sound is passed into the bladder; 
if the sound and the finger meet above the presenting tumour the 
evidence is conclusive that inversion exists. 

The prognosis of inversion of the uterus is never favourable, 
although A. F. Jones, of Omaha, reports a case of spontaneous reduc- 
tion of an inverted uterus three years after the occurrence of the acci- 
dent. Crosse studied the histories of nearly 400 cases, with the result 
that he ascertained the mortality from this condition to be nearly 35 
per cent, death occurring either very soon after the accident or within a 
month. Of 109 fatal cases, the fatal termination in 72 ensued within a 
few hours, and in the majority within half an hour. Eight died in from 
one to seven days and six in from one to four weeks. After the first 
month the danger is slight, but it begins again with the resumption 
of menstruation, which has a tendency to become hemorrhagic. 
Orampton's table {American Journal of Obstetrics, October, 1885) re- 
veals the fact that of 120 recent cases, 87 recovered, 32 died, 1 remained 
unrelieved. Twelve of the cases, however, were moribund when first 
visited. In the fatal cases, reposition was usually effected readily 
enough, but too late to save life. Of 104 chronic inversions, 91 recov- 
ered, 7 died, and 6 remained unrelieved. The average mortality as 
shown by Crampton's table is about 20 per cent. Pregnancy may 
occur, followed by normal delivery, in cases in which the uterus has 
been inverted and has either reduced itself spontaneously or has been 
reduced by operation. 

The pathology of this condition is by no means distinct. When 
the accident occurs in the puerperal state the probably one essential 
factor in its causation is uterine inertia, which is a functional rather 
than an organic condition. After the occurrence of puerperal inver- 
sion, the womb, if left in position, seems to undergo the ordinary 
course of involution. Aside from the malposition there seems to be 
no special pathologic state induced. Treub, of Amsterdam, made a 
careful microscopic examination of a uterus which he removed for 
nonparturient inversion, and found the muscular structure normal 
with absolutely no appearance of atrophy. There existed, however, a 
very ©edematous hypertrophy of the exposed mucous membrane. 

The treatment of inversion of the uterus differs materially in acute 
and in chronic cases. In acute cases — i. e., those of recent occurrence — 
the first indications are to secure hemostasis and to effect reduction. 
The hand should be immediately inserted into the vagina and upward 
pressure should be exercised by the fingers directly against the centre of 
the protruding mass, while counter pressure should be exercised from 
above by a hand placed against what may now be designated as the 



328 A TEXT-BOOK OF GYNECOLOGY 

cervical ring. It is better to conduct the intravaginal manipulations 
under a current of water heated to 110° F., or, preferably, water and 
vinegar, half and half, brought to the same temperature. Vinegar 
is an excellent hemostatic with distinct antiseptic properties. If the 
fountain syringe or other reservoir is hung very high, the hydrostatic 
pressure thereby secured becomes an additional force available in the 
work of reduction. If these measures do not at once control the 
hemorrhage, and if its continuance for any length of time is a menace 
to the patient's life, an elastic band should be placed around the neck 
of the protruding mass and should be left in situ for several hours. It 
should not be adjusted so tightly as to induce strangulation, nor 
should it be left on so long as to produce destruction of the tissue. 
When it is unwound the hemorrhage will generally be found to have 
ceased, in which case manipulations looking to the reduction of the 
organ should be resumed. Mechanical repositors, consisting of a 
staff with a bulbous extremity, may be made from wood or other ma- 
terial and used with persistent pressure. Lawson Tait utilized con- 
stant elastic pressure, which he applied to a repositor by means of an 
elastic perineal belt fastened before and behind to an abdominal girdle. 
There are some dangers attached to this method of treatment. If the 
intrauterine extremity of the repositor is not very blunt, or else bulb- 
ous or cup-shaped, an apparently slight elastic pressure may be suffi- 
cient to force it through the soft uterine tissues. Then, too, if the 
repositor with a large bulb, or a cuplike intrauterine end, succeeds in 
accomplishing its purpose, the instrument itself may become incar- 
cerated by contraction of the cervix. While this complication is by 
no means insurmountable, it has proved embarrassing. If the extem- 
porized repositor is made of wood or other porous material, it may 
speedily become septic and a consequent source of extreme danger. 
To avoid this accident, it should, if conveniently possible, be given 
two or three coats of shellac before being used. 

The treatment of chronic inversion of the uterus has been a source of 
great perplexity since the days of Hippocrates. This master genius de- 
scribed with great fidelity the condition of inversion, which he treated 
by placing the woman on her back, upon a couch, elevating her feet, 
extending her legs, and applying compresses and sponges against the 
tumour, holding them in place by means of a perineal bandage. This 
was kept up for seven days. If it failed, the woman's womb was 
anointed, she was fastened by her heels to a ladder with her head hang- 
ing down, and was violent^ shaken with the object of thus reducing 
the displaced organ. Strange as it ma}^ seem, Castex, as late as 1859 
(Gazette liebdomadaire de medecine et de cliirurgie), reported the success- 
ful adoption of this Hippocratic practice by a Moorish midwife at 
Tangier. The condition and its treatment through the succeeding 
centuries commanded the attention of Ehazas, Avicenna, Aretaeus, and 
Themison, among the ancients. 

Various modern methods have been devised to effect the reduction 



DISPLACEMENTS OP THE UTERUS 329 

of chronic inversion of the uterus. White, of Buffalo, as long ago as 
1858, published a plan of reduction by continued pressure, which he 
applied by adjusting the soft rubber cup-shaped end of a repositor 
against the presenting fundus of the uterus; to the other end of this 
repositor a spring capable of maintaining ten pounds pressure was 
adjusted, and so arranged as to lie against the breast of the operator. 
Pressure was thus exerted, while counter-pressure was made by the 
hands against the cervical ring, the pressure being exercised through 
the abdominal wall. This method was modified by Tyler Smith, Ave- 
ling, Wing, Robert Barnes, Lawson Tait, and others, but with no 
essential deviation in principle. 

Carl Braun, in 1851, introduced a method of reduction by vaginal 
tamponade by means of a caoutchouc bag which he called a colpeuryn- 
ter. When this bag is properly adjusted to the uterus, the latter is 
pressed upward in such a way as to place the vaginal attachments upon 
the stretch, causing them to draw open the cervical cavity by lateral 
tension, thus acting not only as a dilator but as a repositor. The 
same principle is applied to-day by many practitioners. Neugebauer 
utilizes an intravaginal elastic bag which is gradually distended with 
water from a high plane. The hydrostatic pressure thus induced is 
found to be effective, a case in which the inversion had existed for two 
years having been thus reduced in nineteen days. The patient suffered 
no pain and learned to fill and empty the bag herself when it was 
necessary to relieve the pressure upon the urethra. 

When conservative means at reduction fail, recourse must be had 
to surgical intervention. T. Gaillard Thomas advised an operation of 
forcible dilatation of the inverted uterine canal. This was practised 
by first making an abdominal section, stretching the uterine tissues 
by means of a strong uterine dilator, and then reducing the uterus 
by conjoined manipulation. The mortality following this operation was 
large and it has been practically abandoned. The principle involved 
in Gaillard Thomas's operation, viz., the forcible dilatation of the 
inverted uterine canal, has been so modified as to avoid the necessity 
of the preliminary abdominal section. This modification consists in 
drawing down the uterus carefully enveloped about its neck with some 
sterilized gauze. An incision is then made through either the anterior 
or the posterior uterine wall, and through this incision a dilator is 
introduced. When the dilatation has been carried to a sufficient de- 
gree, as determined by the introduction of the finger through the 
operation wound and through the now dilated cervical canal, the 
incision is sewn up with sterilized catgut and the fundus is forced back 
into position. Kehrer (Centralblatt fur Gynakologie) draws the in- 
verted uterus down to the entrance of the vagina and makes an incision 
on its anterior surface through the whole length of the cervix from 
the os externum to a little beyond the middle of the corpus, and ex- 
tending directly through into the peritoneal cavity. The wound is 
then stitched from the fundus to the os internum, after which the 



330 A TEXT-BOOK OF GYNECOLOGY 

inversion is reduced, when, finally, the lower part of the wound is 
sewn up as far as the os externum. 

Hirst operates by dividing the posterior cervical wall as far up 
as may be necessary to gain space through which to effect the reduc- 
tion, which he has been able to do without making the extensive inci- 
sion of Kehrer. After the uterus has been restored by Hirst's method, 
the only remaining step consists in applying a few interrupted sutures 
to the incised posterior lip. This operation impresses one as being at 
once simple and effective. 

Vaginal hysterectomy as a remedy for chronic and irreducible 
inversion of the uterus is not a modern conception. Themison sug- 
gested it b. c. 50, but it was not adopted in practice until Soranus, of 
Ephesus, amputated an inverted uterus about the end of the second 
century of our era. The suggestion has been recognised as one of 
practicability from that day until the present. In its adoption the 
general principles of technique should be observed that are outlined in 
the chapter on vaginal hysterectomy. 

In view of the fact that the inverted uterus, when once restored, 
is capable of exercising the functions of reproduction, vaginal hyster- 
ectomy should not be performed in child-bearing women. 



CHAPTER XXV 
INJURIES OF, AND FOREIGN BODIES IN, THE UTERUS 

Injuries: (a) parturient: rupture, laceration of the cervix — Trachelorrhaphy (Em- 
met) — Amputation of the cervix — (b) nonparturient : wounds from external 
causes — Foreign bodies. 

Injuries of the uterus divide themselves naturally into (a) par- 
turient, and (b) nonparturient. 

Rupture of the uterus is an accident of parturition. It may be 
complete or incomplete. In the latter, the injury is restricted to the 
muscularis while the peritoneum remains intact. This was regarded 
by Lusk as more likely to occur in lateral tears at the site of the folds 
of the broad ligament — though, owing to the relatively loose attach- 
ment of the peritoneum at the lower segment, incomplete ruptures 
are not necessarily confined to those points. In the complete form 
the tear extends through the muscularis and the peritoneum, making, 
usually, a communicating wound with the abdominal cavity, although 
lacerations have occurred in that zone of the uterus which lies in 
normal attachment to the bladder. 

The causes of rupture of the uterus may be summarized by saying 
that they may consist of any condition that interferes with the descent 
of the child, that favours the ascent of the body and fundus, or dimin- 
ishes the normal powers of resistance of the uterine walls. A mon- 
strosity, a hydrocephalic head, neglected shoulder presentation, are 
examples of causes that may exist in the foetus. Fibroid tumours, dis- 
tortion of the pelvis, and malignant disease of the cervix, are among 
the maternal causes. Some writers have placed emphasis upon fatty 
degeneration of the uterine parenchyma as a demonstrated cause of 
this condition. 

The mechanism by which uterine ruptures are caused was first 
satisfactorily explained by Bandl. He explained that in normal 
labour the contractions of the uterus resulted in a thickening of the 
fundus and body, while the lower segment was stretched and thinned 
by the downward pressure exercised by the presenting part of the 
foetus. This process was strictly physiologic, so long as no obstacle 
existed to interfere with the descent of the child. The natural result 
of this dilatation was the practical conversion of the uterus and vagina 
into a continuous canal. When labour was advanced, the lower circum- 
ference of the body of the uterus was ordinarily distinguished from 

331 



332 A TEXT-BOOK OF GYNECOLOGY 

the stretched lower segment by the ridge induced by the contractions, 
and now known as the ring of Bandl. This ring was ordinarily found 
in the neighbourhood of the pelvic brim, but its development was 
proportionate to the difficulty of the labour. In the presence of 
some obstruction to the normal descent of the child, the retentive 
force exercised by the suspensory ligaments of the uterus resulted in 
the upward retraction of the fundus and body of that organ. This up- 
ward migration of the superior zone of the uterus resulted in a cor- 
responding upward migration of the contraction ring, or the ring of 
Bandl. The ascent of this ring deprived the lower segment of the 
uterus of those accessions to its volume and resistant force, which, 
under normal circumstances, would be derived from the natural dilata- 
tion of the ring of Bandl. As a consequence, the lower, or cervical, 
structures became stretched and thin, often to a degree that they could 
no longer maintain their integrity against the expulsive and divulsive 
force from within. In this way, according to Bandl's explanation, 
the majority of all ruptures of the uterus begin in the lower segment, 
a philosophic conclusion which is amply confirmed by clinical observa- 
tion. The view has been urged that, while ruptures of the uterus, for 
the reasons already given, generally begin in the lower segment and 
extend upward, their further extension toward the fundus is arrested 
by the action of the now migrated ring of Bandl, which, in certain 
cases, may be felt through the abdominal walls above the pubis, or, 
even as high as the umbilicus. Many of the ruptures reported, indi- 
cate that a tear probably started in the lower segment of the uterus, 
and extending upward part way to the fundus, had been deflected to 
one side or the other. This was manifested in two cases by Eeed. 
(New York Medical Journal, November 9, 1889.) 

The symptoms of rupture of the uterus, when partial, may consist 
of only an evanescent and not severe shock, a temporary interruption 
of the pains, and a persistence of hemorrhage after delivery. When 
the rupture is complete, however, the phenomena induced by the 
accident are striking and unmistakable. There is profound shock; 
the uterine contractions and pain cease instantly; the presenting part 
of the child recedes; the fundus of the uterus tilts to one side, or 
entirely disappears in the presence of a new, strange, and indefinite 
tumefaction within the abdomen; a bloody discharge makes its appear- 
ance; and frequently there is prolapse of the funis. A careful exam- 
ination at this time will indicate, not only a recession of the presenting 
part of the child, but an apparent atony of the cervical structures. If 
the child has escaped into the abdominal cavity, the hand is intro- 
duced without difficulty into the uterus, and may, in certain cases, be 
carried through the rent in the uterus into the peritoneal cavity. The 
diagnosis, according to Ludwig, is not always easy, even when the fore- 
going symptoms are taken into account. He has found the best diag- 
nostic sign to be, (a) in lateral rupture, the interruption of the natural 
contour of the uterine quadrant, when either a projection or a nodule 



"TT 



INJURIES AND FOREIGN BODIES OF THE UTERUS 333 

is formed; (b) suddenly acquired abnormal mobility of the uterus; and 
(c), a sign upon which he places great emphasis, viz., emphysematous 
crackling at the seat of rupture. If the head presents and can be 
pushed back, the bimanual examination under deep narcosis makes the 
diagnosis certain. 

The treatment of rupture of the uterus is to be directed to the 
saving of the life of both the mother and child, when possible. If the 
child is yet within the uterine cavity, the vertex presenting, forceps 
should be applied without delay; if breech or shoulder is presenting 
and the child is known to be alive, version may be practised. If the 
child is still within the uterine cavity but is known to be dead, it may 
be delivered by craniotomy, morcellement , or by any other means that 
will most speedily empty the uterine cavity. After delivery the 
uterine cavity should be carefully explored, and, if the rupture is found 
to communicate with the peritoneal cavity, an abdominal section 
should be done at once. If rupture has been complete and has been 
followed by the escape of the child into the peritoneal cavity, the child 
should be delivered by abdominal section. The same course is to be 
followed when the child has been delivered per vias naturales, and the 
placenta has escaped into the abdominal cavity — indeed it may be 
adopted as a safe rule that the abdominal cavity should be opened 
whenever rupture of the uterus can be demonstrated to be complete, 
no matter what may or may not have passed through the rent. This 
conclusion is based upon the fact that although neither the child nor 
the placenta may have escaped into the abdominal cavity, complete 
rupture could not occur without the escape into the peritoneal cavity 
of either blood, amniotic fluid, or other products of gestation, liable 
to be either the bearers or the sources of infection. The abdomen 
should in such cases be opened and thoroughly washed out with normal 
salt solution. If hemorrhage is in progress, it should be controlled 
either by the application of forceps to the broad ligaments, far enough 
down to control, not only the ovarian, but the uterine arteries; or by 
an elastic ligature temporarily applied below the site of rupture. The 
treatment of the uterus at this point is one of extreme importance. 
The rent may be closed, which is best done by paring the edges, and 
approximating and closing them by the seroserous suture, adopted by 
Czerny and Lembert, in Cesarean section (see Cesarean Section); or 
the uterus may be removed, converting the procedure essentially into 
a Porro operation. Unless there is extensive destruction of the tissues 
of the uterus, with obvious infection, its removal is not justifiable. 
Women who have sustained rupture of the uterus and who have been 
successfully operated upon by closure of the tear, have subsequently 
borne children. Deutsch (Centralhlatt filr Gynlikologie, November 
14, 1889) reported a case of symmetrically contracted pelvis in which 
rupture of the uterus had been treated by abdominal section four years 
previously. The patient went to term, when examination revealed the 
uterus adherent to the abdominal wall, causing a marked projection 



334 A TEXT-BOOK OF GYNECOLOGY 

of the abdomen. The foetus being found to be living, the patient was 
narcotized, the os was dilated, and a living child was delivered by po- 
dalic version. If carcinoma or fibroids are either the underlying cause 
or the associated condition of a rupture of the uterus, no hesitancy 
about its ablation need be entertained. The operation should be 
done as soon after the condition is detected as necessary preparations 
can be made. The possibility of hemorrhage and the still greater pos- 
sibility of infection make it imperative that intervention should be 
practised as speedily as possible. Patients may, however, live for a 
considerable time after the occurrence of this accident, even without 
treatment. Thus St. Braunwas, of Cracow, reports a case in which 
he had extracted the foetus by abdominal section six weeks after it 
had escaped through a rupture of the uterus into the peritoneal cavity. 
The foetus was bathed in pus, which filled the cavity of the abdomen. 
The patient, of course, died from chronic sepsis. In cases in which 
abdominal section is practised, the operation proper should be both 
preceded and followed by free administration of normal salt solution, 
either by intravenous injection or by hypodermoclysis. 

Lacerations of the cervix occur chiefly as accidents of childbirth — 
although latterly they are encountered in occasional instances as re- 
sults of forcible dilatation of the cervix. (See Dilatation of the Cer- 
vix.) When this operation is performed with too much rapidity and 
by one of the powerful instruments now in use, the divulsion may 
result, not merely in the separation of submucous fibres, but even in a 
complete severance of continuity of the cervical tissue. It may be 
said that laceration of the cervix, when occurring as the result of for- 
cible dilatation or of parturition, is always caused by divulsion carried 
to a point beyond the resistant power of the cervical structures. Lac- 
erations of the cervix may be either superficial or deep, extending as far 
up as the cervico-corporeal junction, and are, in reality, but examples 
of rupture of the uterus, the damage occurring in the lower segment 
of that organ and involving the cervical margin. More than one rup- 
ture of this kind may occur at once, occasioning what is spoken of as 
multiple or stellate laceration of the cervix. When lacerations occur 
chiefly within the cervical canal, but do not extend entirely through 
to the lateral vaginal surfaces of the cervix, they may result in a 
permanent enlargement of that canal. The attention of the profes- 
sion was first called to the pathologic character of these injuries by 
Emmet, who devised the operation for their repair. (See Trache- 
lorrhaphy.) 

The pathology of lacerations of the cervix relates chiefly to ante- 
cedent and subsequent changes. The antecedent changes consist of 
those modifications of the cervical structure — e. g., fatty degeneration 
and oedema — occurring during the course of pregnancy, which result 
in a loss of the normal elasticity of the tissues. The subsequent 
changes relate to those interferences with involution, and those modifi- 
cations of local nutrition, which are caused by the tear, and the con- 



INJURIES AND FOREIGN BODIES OF THE UTERUS 335 

sequent interference with the circulation. After the receipt of the 
injury, laceration of the cervix rarely if ever heals spontaneously. 
Eepair occurs by process of cicatrization; the tissue thus formed subse- 
quently contracts; and the underlying cervical structures are distorted. 
When the laceration is bilateral the resulting contraction of the cica- 
tricial tissue causes a retraction outward of the cervical lips, with con- 
sequent eversion of the mucous membrane. The mucous membrane 
itself, exposed on the everted surfaces of the cervix, presently under- 
goes glandular hypertrophy, giving to the unpractised eye the appear- 
ance of ulceration, and abounding in granulations. There is no doubt 
that many of the so-called " ulcerations of the womb," treated in the 
years gone by with repeated applications of lunar caustic, were, in 
reality, but eversions of the endocervix in a state of glandular hyper- 
troph} r . The enlarged follicles of the cervical mucosa manifest an 
augmentation of function corresponding with their abnormal develop- 
ment; and, as a consequence, the cervix is always covered in such cases 
with a clear viscid mucus, sometimes tinged with blood. Changes in 
the parenchyma of the cervix are equally marked and may present two 
extremes, namely, atrophy or hyperplasia. When the laceration is 
comparatively superficial, the resulting inflammation goes through all 
the consecutive stages from preliminary engorgement to final atrophy; 
but when the laceration is deep and the consequent cervical eversion 
is pronounced, there is so much mechanical interference with the 
circulation, particularly upon the venous side, that passive engorgement 
ensues, resulting finally in an actual increase of the tissue elements. 
This state of hypertrophy is sometimes associated with oedematous in- 
filtration; but, as a rule, there occurs an organization of the adventi- 
tious tissue elements with consequent enlargement and induration of 
the cervix. These changes may be more pronounced in some parts of 
the cervix than in others, the difference being determined by the 
location, depth, and consequent influence, of the laceration. The body 
and fundus of the uterus, being largely supplied with blood by the 
ovarian artery, and being drained by the ovarian veins, are not subject 
to the influences arising in the injury of the cervix. It is noticeable, 
however, notwithstanding the fact that the upper zones of the uterus 
possess a practically independent circulation, that they undergo the 
post-parturient involutional changes tardily in the presence of deep 
injuries of the cervix. Glandular hypertrophies are, consequently, 
not uncommon in these cases in the corporeal endometrium. (See 
Endometritis.) The inflammations producing this increase in tissue, 
both glandular and parenchymatous, are manifestly dependent in a 
large degree upon mechanical disturbances of the pelvic circulation; 
but, from the facts that lacerations of the cervix never heal without at 
least superficial bacterial invasion, and that infection once established 
at the seat of laceration readily extends upward, these inflammations 
must be recognised as infectious quite as much as traumatic. 

Symptoms of laceration of the cervix at the time of its occurrence 



336 A TEXT-BOOK OF GYNECOLOGY 

may be absolutely nil. The absence of all symptoms indicating lacera- 
tion of the cervix accounts for the fact that the majority of these acci- 
dents are never discovered until long after their occurrence, when the 
patient presents herself for treatment for vague and indefinite pelvic 
symptoms. In occasional instances, however, the laceration is so deep, 
extending up to and involving the circular artery, that hemorrhage 
results. This symptom is often overlooked for a time under the im- 
pression that the flow of blood is nothing more or less than that which 
occurs in normal cases following delivery. When, however, this hemor- 
rhage persists for a considerable time, imparting an arterial tinge to 
the otherwise dull-coloured lochia, it becomes the occasion for a local 
examination. Digital exploration at this time, particularly if done 
by an inexperienced operator, is liable to be negative, if not misleading, 
in its results. The cervix during the first few days following delivery 
is enlarged, dilated, cedematous, and flabby; its normal contour can 
not be detected, while superficial abrasions, or even deep lacerations, 
can not be distinguished by the touch. Under these circumstances the 
patient should be placed in the Sims position, the perineum should be 
retracted, and the cervix should be drawn down and carefully inspected, 
when the bleeding point, if within the area of a laceration, can be 
detected and controlled. In the later stages of a laceration — i. e., sev- 
eral weeks or months after delivery — there is vastly less difficulty in 
detecting the actual conditions. The patient may or may not com- 
plain of pain. Cicatricial deposits, particularly in the angle of lacera- 
tion, and especially in cases of long standing, may impinge upon ter- 
minal nerve filaments and occasion severe distress, and that not only 
in the uterus, for through its intimate nerve connections with both 
the sympathetic and cerebro-spinal systems, this relatively slight local 
injury may cause a widespread perturbation of nerve function. It 
would seem in certain cases, as if the cervix under these circumstances 
were a sort of central telegraphic office, with radiating lines over which 
morbific impulses are telegraphed to the remotest parts of the system. 
Erratic behaviour of the apparatus of accommodation, eccentric dis- 
turbances of hearing, evanescent or persistent turgescences of the turbi- 
nates, congestions of the Schneiderian membrane, asthmatic disturb- 
ances, localized variations of cutaneous sensibility, and that congeries 
of nerve perturbations designated as hysteria, have been known to fol- 
low in the wake of this accident and to have been cured by repair of 
the cervix. These so-called reflex symptoms, however, never occur 
with that degree of constancy necessary for them to be accepted as 
indications of an existing laceration of the cervix. It may be said in 
short that there are no symptoms of a subjective character that are 
pathognomonic of this condition. Local examination alone detects 
the condition, which has existed, possibly, for years, without being 
suspected, either by the patient or her medical adviser. Introduction 
of the finger into the vagina will reveal the cervix with an irregular 
contour; it may be multilobular, each lobule being divided by a distinct 



; ^ 



INJURIES AND FOREIGN BODIES OF THE UTERUS 337 

fissure (stellate laceration), or it may be divided into an anterior and a 
posterior lip (bilateral laceration), or it may be fissured upon only one 
side (single laceration). If examined by the speculum, these appear- 
ances may be much modified; as, for instance, if a bivalve speculum 
is employed, its dilatation will result in stretching farther apart 
the antero-posterior lip of the cervix in a bilateral laceration; indeed, 
in cases of long standing in which the eversion has become pro- 
nounced, the retracted lips may have been drawn up to the utero- 
vaginal junction, and, when distended by means of a bivalve speculum, 
the marginal contour of the cervix may entirely disappear. The pic- 
ture presented in the speculum will be that of a double, elliptical, area 
of apparent erosion. This will be nothing more or less, in practically 
every case, than the hypertrophic endocervium. If, now, this patient is 
placed in the Sims posture, the perineum retracted, and the retractor 
intrusted to an assistant, the examiner may, by means of a volsella 
placed in the apex of each lip, draw the severed portions of the cervix 
into approximation. He will thus be enabled to determine the depth 
and other exact characters of the laceration. 

The complications of laceration of the cervix are worthy of con- 
sideration. They naturally coexist with atrophies, hypertrophies, or 
hyperplasias of both the parenchyma and endometrium. As already 
indicated when considering the pathology of this lesion, bacterial in- 
fection of the laceration takes place at the time of its occurrence; pro- 
gressive invasion, either of the contiguous mucous surfaces or of the 
opened lymph spaces, ensues; the result being either infection and 
enlargement of the pelvic lymphatic glands, with possible resulting 
suppuration, or infection with purulent accumulation in the Fallopian 
tubes, involving the ovaries in the general pathologic processes. These 
complications are frequently encountered and are directly traceable to 
the original injury for their causation. It not infrequently happens 
that laceration is not detected until an examination is demanded for 
symptoms of carcinoma. This disease, indeed, exists as a frequent 
complication of laceration, the carcinomatous process in many in- 
stances having its origin in the cicatricial covering of a cervical tear. 
Fibroids and other neoplasms may coexist with laceration of the 
cervix. 

The treatment of laceration of the cervix consists essentially in 
restoring that structure, so far as possible, to its normal state. The 
steps by which this may be accomplished must vary according to the 
pathologic conditions present in the case; thus, if the case is one 
simply of laceration without marked tissue changes, the treatment will 
consist in revivifying the margins of the wound and approximating 
them by sutures; if, however, there is extensive hypertrophy, it may 
be necessary to remove, at least, a part of the enlarged segment of 
the uterus. At the same time, associated pathologic states in the 
endometrium must be appropriately treated. 
23 



338 



A TEXT-BOOK OF GYNECOLOGY 



Instruments for Trachelorrhaphy 



Catheter, glass 

Curette, dull 

Sharp (Siras's modified) 

Martin's 

Recamier's 

Dilators, different sizes 

Hegar's, three sizes. 
Forceps, hemostatic, two of each size, 

Long dressing 

Rat-tooth dressing. 

Bullet 

Needles, assorted sizes , 



Needle holders 2". 

Nozzles, glass or Edebohls's hard rubber 1 
Retractor, small 1 

Intermediate 2 

Scalpels 2 

Scissors, straight 1 

Shot compressor and shot. 

Sound, uterine 1 

Speculum, Sims's small 1 

Simon's, with handles and four blades 1 

Tenaculum, straight 1 

Tenacula, curved 2. 



Trachelorrhaphy, or the operation for repair of the lacerated cervix,, 
is conveniently done as follows : The patient is placed in the dorsal 

position, her buttocks at the edge of the 
operating table, her knees well drawn up,, 
her flexed legs being intrusted either to 
an assistant or to the efficient mechanical 
attachments of the modern operating 
table. A Jones's perineal retractor with 
a short blade is now inserted and the pos- 
terior lip of the cervix is seized with a 
self-locking volsella and is drawn down. 
Newman has devised an excellent reverse- 
acting, self -locking volsella (Fig. 136) 
which on being inserted into the cervical 
canal and expanded, becomes fixed in the 
uterine tissues. The instrument is an ex- 
ceedingly convenient one, as its shaft lies 
along the mucous track of the cervical 
canal and becomes a convenient guide, 
both in denuding the surfaces and in pass- 
ing the sutures. The downward traction 
on the uterus must be judiciously regu- 
lated, force beyond a few pounds never 
being exercised. Whenever distinct and 
sudden resistance is experienced in effect- 
ing the temporary prolapse of the uterus, 
it is to be construed as an evidence of 
adhesions, and is a danger signal admon- 
ishing the operator against more forcible 
traction. When the uterus is thus drawn 
down, the endometrium, if the seat of 
glandular hypertrophy, should be vigor- 

Fig. 136.— "Newman has devised & n V" ^ -,n -i j 

an excellent reverse-acting, self- OUsly Curetted, the muCUS, blood, and 

locking volsella."— Eeed. debris, being carefully washed away with a, 




INJURIES AND FOREIGN BODIES OF THE UTERUS 



339 



Fig. 137.—" A very 
good knife ... is 
that devised by- 
Newman." — Eeed. 



jet of bichloride water, after which the surface is dried and painted 
with pure carbolic acid. The next step consists in denuding the sur- 
faces to be approximated. Their respective areas should be defi- 
nitely determined in advance by making a preliminary approximation. 
The denudation may be accomplished 
either by a knife or by scissors, prefer- 
ably the former. A very good knife for 
the purpose is that devised by New- 
man (Fig. 137) and its sharp point is so 
arranged that it can be easily passed 
through the cervical tissue in the upper 
angle of the laceration. It is a good 
rule to begin the denudation by first 
outlining with the edge of a bistoury 
the tissues to be removed. These may 
then be cut away, leaving two equal, 
denuded, approximating surfaces. 
Great care should be taken to remove 
the deposit of cicatricial tissue from 
the upper angle of the laceration. In 
the case of a bilateral laceration, all 
the surfaces to be approximated must 
be denuded before the work of sutur- 
ing is begun. The sutures may be in- 
serted by means of a short, heavy, de- 
tached needle, which is employed by 
means of a needle holder; or, they may 
be inserted by means of an obliquely 
curved needle such as that used by Eeed 
(Fig. 138). The sutures themselves 
should be of nonabsorbable material. Emmet does this 
operation with a silver wire, and annealed iron wire 
is employed by some operators. As a rule, however, 
the silkworm gut is the material of preference. Which- 
ever material is employed, careful antiseptic precau- 
tions should be taken. Catgut has been used with suc- 
cess since the process of preparing it with formalin 
and boiling it has been perfected; it generally lasts 
fourteen days, which is long enough, while the facility 
with which the external and unabsorbed remnants are 
removed is a point in its favour. The suture should 
be passed beneath and on a level with each surface 
to be approximated, as illustrated (Fig. 139). Two, 
three, or even four, sutures may be required upon either side, 
the number being governed by the depth of the laceration. After 
all of them have been passed the volsella may be removed, the 
remaining traction on the uterus being exercised by means of the ends 



Fig. 138. 
An obliquely 
curved needle 
used by Eeed." 
— Eeed. 



340 



A TEXT-BOOK OF GYNECOLOGY 



of the sutures on one side being gathered together in a forceps. The 
surface of the wound should be irrigated and removed by means of 
sterilized water. If there is no pulsating hemorrhage, no further atten- 
tion need be given to hemostasis which will be effected by the approxi- 
mation of the surfaces 
and the pressure of the 
sutures. The sutures are 
tied, beginning upon one 
side at the upper angle, 
care being taken that, as 
they are tightened, the 
underlying margins of 
the tissues are brought 
into accurate coaptation. 
Care should be taken to 
avoid tying the sutures 
too tightly, as tissue ne- 
crosis may thereby be in- 
duced and the success of 
the operation be com- 
promised in consequence. 
After being twisted, if 
silver wire is used, or 
tied, if other material is 
employed, the distal ends 
should be cut off about an 
inch from the knot, and 
so arranged as to avoid 
causing mechanical irri- 
tation of the parts. The 
sutures, if of nonabsorb- 
able material, should be left in situ for about ten days, antiseptic 
vaginal irrigation being practised twice daily during the entire 
time. To remove the sutures, the patient should be placed in the 
Sims position and each suture seized with long-fixation forceps and 
subjected to gentle traction. The loop of the suture will thereby 
be drawn up so that the point of a scissors blade may be easily in- 
sinuated beneath it. It is important that the stitches should be re- 
moved under inspection, for, if the effort is made to remove them by 
the sense of touch alone, there is a likelihood of cutting both ends of the 
loop near the knot, leaving the loop itself buried in the tissues. It is 
true that this is not a matter of any serious moment, but it may occasion 
annoying local infection; and the escape of a loop of suture material at 
some subsequent time is always construed by the patient as a more or 
less serious reflection upon the surgeon. 

Amputation of the cervix, in whole or in part, is demanded for 
hypertrophic and hyperplastic conditions that are sometimes associated 




Fig. 139. — " The suture should be passed beneath and 
on a level with each surface to be approximated." — 
Eeed (page 339). 



INJURIES AND FOREIGN BODIES OF THE UTERUS 341 

with and result from lacerations. Emmet (Transactions of the American 
Gynecological Society, 1897) believes that these conditions should be 
subjected to preliminary local treatment, consisting of douches, elimi- 
native tamponade, alterative topical applications, or even local deple- 
tion by puncture. Treatment of this kind may, in some cases, so far 
reduce hypertrophy that amputation or excision is unnecessary. "When, 
however, the desired reduction in the volume and consistence of the 
tissues is not realized by such conservative treatment, Emmet's opera- 
tion of amputation may be adopted. He first draws the uterus down 
by gentle and steady traction to the vaginal outlet, always taking care 
to avoid a jerking movement which would be liable to rupture some 
blood vessel, especially if there has been a pre-existing intrapelvic in- 
flammation. The cervix is steadily held by an assistant just within 
the vaginal outlet, for at this point the arteries will be placed suffi- 
ciently on the stretch to lessen their calibre, and thus to render the 
operation to a great extent bloodless. Care is taken to accurately deter- 
mine the line of vaginal junction, since the bladder will be entered in 
front and the peritoneal cavity behind, if an attempt is made to remove 
what seems to be the cervix over which a mass of thickened vaginal tis- 
sue has been crowded. In those cases in which atrophy takes place as 
already described in this chapter, the field of operation can not be a 
large one at the beginning. An incision is now made round the cervix 
near the vaginal juncture; the subsequent dissection should be made 
by cutting always toward the centre as a precaution against entering 
the bladder and the peritoneal cavity, and with the object of removing 
a cone-shaped piece of tissue. As the operation advances, the excava- 
tion must continually be drawn up to the vaginal level so that the 
operator may have the parts under observation and the bleeding under 
control. As each blood vessel is divided, the neighbouring tissues 
should immediately be seized by an assistant and held as a fresh point 
for traction, when the vessels will promptly retract and cease to bleed. 
The cervix is to be removed segment by segment until underlying 
healthy tissue is reached. The most efficient instrument for this 
purpose is the pointed scissors which Emmet devised nearly thirty years 
ago for clearing out the angles in the operation for laceration of the 
cervix. After having removed the tissues in the manner just de- 
scribed, nonabsorbable sutures are inserted; Emmet employs the silver 
wire. The sutures are inserted antero-posteriorly. Those to either 
side of the cervical canal are inserted (Fig. 1-10) through the posterior 
lip. into the excavation, into the tissues at the fundus of the excava- 
tion, out again, and then through the anterior lip of the wound. The 
sutures that are passed coincidently with the cervical canal are intro- 
duced through the posterior lip of the wound, out again, in again 
through the posterior lip of the cervical canal, and out through the 
cervical canal. Another suture is passed similarly to the last, through 
the lip formed by the anterior wall of the cervical canal, out again and 
through the anterior lip of the cervix. As many antero-posterior 



342 



A TEXT-BOOK OF GYNECOLOGY 



sutures are passed transversely to the cervical canal as may be required. 
" If," says Emmet, " we follow the course of either of these sutures it 
will be apparent that when the front suture, for instance, is twisted, 
the free vaginal surface must be drawn over the stump, and as the edge 
of the uterine canal is a fixed point, the former will be secured at that 
point, and a similar effect will be produced posterior to the cervical 
canal when the posterior suture has been twisted in the same manner. 
The result of thus securing these sutures will be that the edge of the 
divided mucous membrane on the vaginal surface, front and back, will 

be rolled over in contact 
with the edges of the 
uterine canal, and when 
primary union has taken 
place the natural calibre 
of the passage must be 
preserved. But before 
securing these, or any of 
the sutures, as many as 
may be deemed necessary 
should be first introduced 
on each side of the cervi- 
cal canal. Here the loose 
vaginal edge is first 
caught up, and then the 
needle is made to include 
a sufficient portion of the 
uterine stump on a line 
with and lateral to the 
uterine canal, and in turn 
it should take up the 
vaginal tissue behind. 
The only difficulty is in 
catching up enough of 
the uterine tissue in the 
centre of the stump to 
hold it firmly in contact 
with the flaps after the 
sutures have been secured. But this difficulty can be overcome by 
using a properly-shaped needle with the pointed end slightly bent on 
itself. The passage of the needle is greatly facilitated by snipping 
with pointed scissors a sulcus in the tissues at a sufficient depth in 
front of the advancing needle, and from the bottom of this cut its 
point should be brought out to pass over to secure the vaginal 
edge. 

" After all the silver sutures have been twisted it will be made 
evident, by the introduction of a uterine sound for half an inch, that 
the canal has been left fully open, and it will be seen at the same time 




Fig. 140. — " Those to either side of the cervical canal 
are inserted through the posterior lip, into the exca- 
vation, into the tissues at the fundus of the excava- 
tion, out again, and then through the anterior lip of 
the wound." — Eeed (page 341). 



INJURIES AND FOREIGN BODIES OF THE UTERUS 343 

that the vaginal tissues have been drawn over the stump and firmly 
secured to its surface. 

" At the completion of the operation it is necessary that the uterus 
should be carefully replaced with the finger to its natural position, and 
it must be done without displacing the ends of the sutures, which have 
been carefully bent down on to the vaginal surface. As soon as the 
uterus is replaced in its normal position the lateral traction then 
exerted in the vagina will keep the vaginal covering in close relation 
with the stump. 

" Xo surgical operation with which I am familiar yields a more 
uniform and satisfactory result than this one, when performed under 
the following conditions: The proper use of silver sutures, keeping 
the patient in bed for three weeks after the operation including the 
menstrual period when possible, and not removing the sutures before 
the nineteenth or twentieth day, when the parts will have become 
nrmly united and the uterus greatly reduced in size." 

Vesicouterine Fistulae. — These fistula? are of two kinds. In one 
form the cervix is partially destroyed, and in the other form the fistu- 
lous opening occurs into the cervical canal and is so concealed that the 
•cervix must be split during any operation for its obliteration. These 
fistula? can only take place in the cervix. 

It is important that a diagnosis should be made in these cases dis- 
tinguishing between a vesico-uterine fistula and a uretero-uterine fistula. 
In each case the urine is discharged from the os uteri. Sometimes a 
probe can be passed through the fistulous opening from the bladder 
into the cervical canal or vice versa. Clear fluids injected into the 
bladder will come out of the os uteri. If continued pressure is kept 
up in the cervical canal no acute nephydrosis will occur if the 
fistula is vesico-uterine and not uretero-uterine. The electric cysto- 
scope should be of great assistance. With it one should be able to 
make out any perforation of the bladder wall, and thus to distinguish 
between vesical and ureteral fistula?. (See Examination of the 
Bladder.) 

Prognosis. — These fistula? oftentimes heal very kindly owing to 
the fact that the thick wall of the uterus, during the process of heal- 
ing, is likely to close the opening. 

Treatment. — The treatment is the same as that for vesico-vaginal 
fistula, namely, closure by suture. Each of these cases must be judged 
upon its own merits and the operator must think out for himself his 
•exact method of procedure. If the main principles, previously stated, 
are adhered to, he will, in all probability, meet with success. If the 
fistula is situated close to the cervix the anterior lip may be made use 
of to close the opening. If a great deal of the anterior lip has been 
destroyed it will then be necessary to use the posterior lip, and if this is 
done the menstrual fluid will be discharged into the bladder and out 
through the urethra. It is unfortunate to have this happen and if 
possible it should be avoided. 



344 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 



141. — " The bladder, thus separated, should be drawn 
down with a forceps or volsella." — Keed. 



Reed's Operation for Vesico-uterine Fistula. — The condition is 
best controlled by a free incision, dividing the uterus from the blad- 
der, just as is practised in the preliminary step of vaginal hysterec- 
tomy. The bladder, 
thus separated, 
should be drawn 
down with a forceps, 
or volsella (Fig. 
141); the fistula will 
then be brought into 
clear view and can 
be closed by a double 
line of continuous 
catgut sutures. If 
the fistula opens di- 
rectly into the ute- 
rus (Fig. 142), the 
latter should be curetted and packed and a single suture should be 
placed across the orifice of the fistula as it presents at the denuded 
anterior uterine surface. If the fistula traverses the uterus longi- 
tudinally and opens at 
the cervical margin (Fig. 
143), a curved director 
should be inserted and 
the uterine tissues split 
up to the point of en- 
trance of the fistula. If 
the tract has become 
cicatricial it should be 
carefully dissected out, 
and the place that it for- 
merly occupied should be 
closed by repeated inter- 
rupted sutures. In split- 
ting up the uterine tis- 
sues, the circular artery 
is more than likely to 
be divided. The hemor- 
rhage may be somewhat 
difficult to control. This, 
however, is best done by 
passing a deep suture en 
masse to either side of the incision, so situated as to embrace the 
severed ends of the artery within its grasp. 

Both the bladder and the uterus having been thus repaired, the 
parts should be brought into apposition and closed by interrupted 
sutures. The vagina should be packed with antiseptic gauze and the 




Fig. 142. — " The fistula opens directly into the uterus. 
— Reed. 



INJURIES AND FOREIGN BODIES OF THE UTERUS 



345 




i^///M*;'d//> 



usual precautions observed during convalescence. The most notable of 
these precautions is the introduction and retention of a sigmoid cathe- 
ter during several days after the operation. The evacuation of the 
bladder, either by catheter or spontaneously, at intervals of not more 
than three hours during the succeeding week should be rigorously 
practised. 

Wounds of the uterus from external causes are of occasional oc- 
currence. The injudicious use of the uterine sound sometimes re- 
sults in perforation of 
the walls of that organ. 
Cases of this kind have 
been recorded by Law- 
son Tait and others. If 
the instrument is aseptic 
the accident is rarely 
followed hy serious con- 
sequences; if, however, 
infection ensues, death 
may follow. The intro- 
duction into the uterus 
of catheters, sounds, and 
bougies for the purpose 
of inducing criminal 
abortion, generally re- 
sults in more or less in- 
jury to the endometri- 
um, if not to the deeper structures of the wound. Injuries of this kind, 
when inflicted by unclean instruments, result in those deaths from 
constitutional sepsis which occur so frequently in the annals of crime. 
There is probably nothing more dangerous to a woman than an effort, 
particularly on her own part, to induce abortion h\ intrauterine instru- 
mentation. In many cases of perforation of the uterine wall by the 
sound, at the hands of experienced operators, the diseased condition 
of the uterus itself is responsible for the accident. The walls of the 
uterus are very nonresistant in all inflammatory conditions, but par- 
ticularly so in the presence of puerperal infection. In ordinary cases 
of subinvolution, the uterine tissue is very friable. TThen the walls 
of the uterus are soft and eodematous as the result of a flexion at an 
acute angle, the muscularis is easily penetrated; and the same is true 
when the organ is the seat of malignant disease, such, for example, as 
sarcoma, syncytionia malignum, and adenoma malignum. Under these 
circumstances the uterus is sometimes perforated by means of a curette, 
many of these instruments being so constructed that they offer no safe- 
guard against the accident. Gau, of Cincinnati, has devised an ex- 
cellent curette with a safety point and edge calculated to prevent acci- 
dents of this character (Fig. 144). The diagnosis of uterine perforation 
is not difficult. Perforation may be suspected whenever the sound or 



Fig. 143. — " The fistula traverses the uterus longitudi- 
nally and opens at the cervical margin." — Reed 
(page 344). 



346 



A TEXT-BOOK OF GYNECOLOGY 




curette penetrates farther than the previously ascertained limits of the 
uterus. The treatment consists in quietude and vigilance. In a septic 
case it may be prudent to await the development of menacing symptoms, 
which, as soon as they occur, should prompt the surgeon to extirpate 
the uterus. Intrauterine injections are to be carefully avoided, even 
when administered by means of a recurrent syringe, for the reason 
that any force, however slight, may be sufficient to carry infectious 
material from the uterus into the peritoneal cavity. In some cases 
the injury inflicted, particularly by the curette, may cause an opening 
which may result in the protrusion either of omentum or of a loop of 
intestine. In the presence of this complication the protruding struc- 
ture should be replaced and the uterine cavity packed pending the 
completion of preparations for hysterectomy, which should be done 

as promptly as possible. In cases in which 
injury has occurred to the intestines, as 
rarely happens from either the sound or 
the curette, an abdominal section should 
be done at once. 

Gunshot wounds of the uterus, particu- 
larly when pregnant, are recorded. Ben- 
brook {Medical Times) relates an interest- 
ing case of this sort, in which a 44-calibre 
pistol ball passed in just below the crest 
of the ilium going downward and back- 
ward, and a second one entered the ab- 
dominal cavity from a point between the 
eighth and ninth ribs. Three days later, 
the woman was taken with hemorrhage 
from the uterus associated with labour 
pains, and resulting in the expulsion of a 
quantity of blood clot together with a bul- 
let, which had passed into the cavity of the uterus through the fundus. 
Another case by Eobinson {Lancet) revealed the fact that a ball had en- 
tered the abdomen a little to the right and below the umbilicus; an hour 
later labour set in, resulting in the instrumental delivery of a dead child 
near full term, with a gunshot wound in its right shoulder. The ball 
was found in the debris. The mother made an uninterrupted recovery. 
Metert records {Medical Review) an interesting case of a self-inflicted 
gunshot wound in the abdomen of a pregnant woman, the ball passing 
through the uterus and the arm of the child, an abdominal section 
being followed by the recovery of the mother. Gunshot wounds gen- 
erally occur either at the fundus or the anterior wall of the uterus. 
Their infliction is followed by pronounced shock and collapse, pain 
in the abdominal region, at first located at the site of injury, but 
presently becoming diffuse, while symptoms of peritonitis of the dif- 
fuse form shortly manifest themselves. In the course of a few hours 
pains with rhythmic contractions of the uterus occur, whether in the 



Fig. 144. — " Gau has devised an 
excellent curette with a safety 
point and edge." — Reed. 



INJURIES AND FOREIGN BODIES OF THE UTERUS 347 

impregnated or the nonimpregnated uterus. In either instance the 
organ is more or less distended; in the first by the products of con- 
ception, and in the latter by clots. The gravid uterus in many cases 
throws oil: its contents, a fact which does not in the least diminish the 
necessity for prompt intervention. As to treatment, it may be laid 
down as a rule that every case of perforating wound of the abdomen 
of a pregnant woman would be subjected to an exploratory abdominal 
section without reference to symptoms. The probability of perforation 
of the uterus and of the consequent escape of amniotic fluid and 
blood into the peritoneal cavity, makes it imperative that intervention 
should be both prompt and thorough. The fact, also, that in these 
cases the womb and its contents act as a sort of shield to the intestines, 
saving them from injury, increases the prospects of the mother and 
forms an additional reason for speedy intervention. The character 
and extent of the operation must be determined by the conditions 
revealed by the exploratory incision. If there has been extensive 
destruction of uterine tissue, offering no reasonable prospect of recov- 
ery, with the uterus in situ, hysterectomy should be done. This rule 
applies whether the uterus has been emptied or not. All debris should 
be washed from the abdominal cavity by copious irrigation with normal 
salt solution, and intravenous injection or hypodermoclysis should be 
practised in the presence of the generally pronounced shock, or when- 
ever there has been a free loss of blood. If the gravid uterus has 
thrown off its contents, the necessity for abdominal section is all the 
more imperative, for the very contractions of the uterus which result 
in the expulsion of the embryo, result also in the extrusion of the 
liquid contents of the uterus into the peritoneal cavity. 

Cattle-horn wounds of the uterus are of occasional occurrence in the 
cattle-raising districts of the world. A number of these cases have 
been reported describing accidents with revolting details but attended 
with a singularly slight mortality. These injuries considered as ab- 
dominal wounds may or may not involve the uterus; the latter class 
need not be considered in this connection. Of the former it may be 
said that they divide themselves naturally into those wounds which 
involve the uterine wall alone, and those which involve both the uterus 
and the child. The prospect of the child living under these circum- 
stances depends, naturally enough, upon the stage of pregnancy and 
the degree of injury sustained by the child. Occasionally the rent 
in the uterine wall is so great that the foetus and secundines escape 
into the abdominal cavity; and, even under these circumstances, a 
viable child has been known to survive. Harris (American Journal 
of Obstetrics, 1887) collected the histories of nine cases of this char- 
acter, with a mortality of four women and four children. In an injury 
of this character the diagnosis declares itself. Whether a hysterectomy 
should be done in these cases, or whether the wound in the uterus should 
be treated just as in an elective Cesarean section, must be determined at 
the time by the conditions presented. As a rule the uterus contracts 



348 A TEXT-BOOK OF GYNECOLOGY 

vigorously after the receipt of the injury and particularly after being 
emptied. In certain of the recorded cases occurring before the modern 
surgical epoch, closure of the uterine wound was effected by suture, 
and even in cases of recovery the treatment was destitute of those 
features which we should to-day designate as antiseptic. In some of 
the recorded cases subsequent pregnancies with successful deliveries 
have occurred. These facts should prompt the operator to be cautious 
before sacrificing a womb by ablation, even though it may be the seat 
of extensive injury. 

In those cases in which exploratory incision reveals the fact that 
the perforating wound of the uterus is small, delivery may be effected 
by the Cesarean section. (See Csesarean Section.) In such cases it 
is important that the gunshot wound be carefully closed on the peri- 
toneal surface of the uterus. 

Foreign bodies in the uterus are occasionally encountered in prac- 
tice. They may consist of pledgets of cotton or of gauze left by acci- 
dent in the uterine cavity in the course of treatment, the broken end 
of a uterine electrode, or the stem of an intrauterine pessary. Schauta 
(Ceniralblatt fur Gynakologie) reported a case in which a hard-rubber 
pessary, 2.5 inches in long diameter, inserted into the vagina, had 
escaped into the uterine cavity from which it was delivered with ex- 
treme difficulty by morcellement. Neugebauer, in his collected series of 
297 cases of pessaries neglected and incarcerated in the vagina or 
escaped into adjacent parts, notes six in which a vaginal pessary slipped 
into the uterus. Bodies usually found in the uterine cavity are hairpins 
or broken-off ends of instruments employed for the most part by 
patients themselves in an effort to produce abortion. 




Fig. 145. — " W. E. Ashton reports an interesting case in which ... a false passage was made 
from the internal os through the anterior uterine wall." — Reed. 

W. E. Ashton reports (Medical Bulletin) an interesting case (Fig. 
145) in which, as the result of an attempt to forcibly insert a tupelo 
tent, a false passage was made from the internal os through the an- 
terior uterine wall to a point above the utero-vesical fold where the 
tip of the tent protruded into the peritoneal cavity. Laminaria and 



INJURIES AND FOREIGN BODIES OF THE UTERUS 349 

other tents introduced into the cervical canal have escaped into the 
uterine cavity proper. Mittermaier reports a case in which a loosely 
tied silk ligature had become the nucleus of an infection and of a 
foreign body following an operation for fibroid, and another case 
in which the glass catheter used for irrigating the uterine cavity had 
broken in situ, the fragments having become so thoroughly embedded 
that all attempts to remove them had proved futile. The diagnosis 
of some of these cases in the absence of a definite history can be made 
only by forcible dilatation of the cervix, and either instrumental or 
digital exploration of the uterine cavity. The treatment consists in 
dilating the cervix and, if possible, removing the foreign body. This 
is sometimes a matter of extreme difficulty. Thus Schauta, in his 
efforts to remove the long incarcerated pessary from the uterine cavity, 
perforated the latter repeatedly with a Pacquelin cautery for the pur- 
pose of getting some means of grasping the ovoid body. The removal 
of smaller foreign bodies can generally be effected by means of the 
curette, the Emmet curette forceps, or the Lawson Tait colpocystotomy 
forceps. In some cases, however, this will prove unavailing; thus, Mit- 
termaier found it impossible by such means to remove the fragments of 
broken glass from the cavity of the uterus, to accomplish which he had 
to divide the uterus from the bladder, draw the fundus down into the 
vagina, and make an incision into the uterine cavity. Having removed 
the glass, he stitched up the incision, and returned the womb to its nor- 
mal position. It is important to bear in mind in cases in which such an 
operation is necessary that the operation should be made anteriorly, 
rather than posteriorly, to the cervix. When a foreign body results in 
injury and consequent infection, hysterectomy may be done, as Ashton 
did successfully in the case to which reference has just been made. 



CHAPTEE XXYI 

INFECTIONS OF THE UTERUS 

The uterus — The endometrium — The myometrium — Bacteria of the uterus — Infec- 
tions : (a) Mixed, (b) specific — Endometritis and metritis — Pathology — Causes — 
Symptoms — Diagnosis — Treatment : (a) Topical, Reed's method ; (6) curettage. 

The uterus being a frequent seat of infections, a proper compre- 
hension of them mnst presuppose a knowledge of (a) the endometrium,. 
(b) the myometrium, (c) the bacteria of the uterus, and (d) the recog- 
nised infections in their clinical, pathological, and therapeutical aspects. 

The endometrium consists of a stroma of fibro-connective and mus- 
cular tissues in which are embedded glands covered by a single layer of 
columnar ciliated epithelium. It contains lymphatics and nerves, and 
the mucous glands are large and numerous. The endometrium is not 
supplied with separate blood vessels, but receives its nutrition from 
the superficial capillaries of the uterus. The ciliated columnar epithe- 
lium lines the entire uterus, also the uterine glands, and is continued 
through the Fallopian tubes. As the endometrium approaches the 
external os it loses its cilia and becomes blended with the pavement 
epithelium upon the vaginal portion of the cervix. The glands are 
tubular and narrow, dip down to the muscularis, and constitute a large 
portion of the volume of the endometrium. These glands are active 
and maintain a free secretion upon the surface of the membrane, with 
a plug of thick mucus in the cervical canal. Lymph spaces and vessels 
are abundant throughout the uterus, lying in the interglandular spaces 
around the bundles of muscular fibres and in the serosa, and con- 
verging into large channels which pass outward in the broad ligaments. 
The cervical endometrium has a peculiar arbor vitse arrangement, is 
more dense than the corporeal, and is attached to the muscularis by 
looser tissue; it does not participate in menstruation. The normal 
secretion of the endometrium is alkaline in reaction; the corporeal 
mucus is clear and watery, the cervical, viscid. One important func- 
tion of the cervix is to close as by a sphincter the uterine cavity; the 
great function of the corporeal endometrium is to form the decidua 
and nourish the embryo. A knowledge of this function of the cervix 
should of itself forbid the much-abused operation of forcible cervical 
dilatation in virgins. The gland crypts of the cervix readily become 
a culture bed for germs, which may long remain therein in an attenu- 
350 



INFECTIONS OF THE UTERUS 351 

ated form, and under favourable conditions develop new cultures and 
activity. 

The endometrium, says MeMurtry, is one of the most variable tis- 
sues of the body. It is subject to alterations that are physiologic, 
so that it is most difficult to establish a normal appearance that is 
typical. This fact often leads to a mistaken diagnosis of endometritis. 
The endometrium is suffused with blood during menstruation, under- 
goes marked disintegration at that time, and is afterward regenerated. 
During adolescence there is an increase in glandular tissue; during 
pregnancy this is even more marked, and atrophy supervenes after 
the menopause. The blood supply of the uterus is altered by physio- 
logic and pathologic conditions extraneous to that organ, such as nerv- 
ous states and wasting disease. These observations are of the utmost 
importance in the practical diagnosis and treatment of uterine dis- 
eases, and will convince the painstaking observer that the common 
diagnosis of endometritis, followed by aggressive instrumentation and 
chemical antisepsis, is a grave error both in diagnosis and treatment. 

The secretion of the uterine cavity is alkaline; that of the vagina 
acid. Under normal conditions, the acid secretion of the vagina is a 
protection from pathogenic organisms and the endometrium is always 
sterile. Pathogenic cocci and other germs which might enter from 
adjacent cutaneous surfaces perish in the acid vaginal secretions, which 
are unsuited for their growth. The reaction of the vagina, however, 
may be altered by the presence of inflammatory products, so that in- 
fection may occur through this route. 

The epithelium on the crests of the endometrial folds is usually 
described as having cilia, which Wyder insists have a motion from the os 
internum toward the fundus. Hofmeier (Centralblatt fur Gynakologie) 
criticises this view. Not only were his own studies conducted upon 
fresh uteri removed from mammals, in which the conditions ought to be 
the same as in the human female, but he also examined organs removed 
at the operating table and at once immersed in warm saline solution. In 
several of these latter he demonstrated conclusively, by removing strips 
of endometrium and placing them under the microscope, that minute 
particles of charcoal were invariably carried by the ciliary movement 
from the fundus toward the os internum. 

This observation of Hofmeier's seems at least to be in harmony 
with an intelligent design of Nature by which obstacles are interposed 
to the easy invasion of the upper reaches of the genital tract. 

The endometrium, responsive to the increased nutrition which 
comes from the premenstrual afflux of the blood to the pelvis, under- 
goes a sort of periodical hypertrophy, preceding each onset of the 
monthly flow. (See Normal Menstruation.) The exuberant epithe- 
lium undergoes a sort of desquamation. Yon Kohlden (Centralblatt 
fiir Gynakologie), who has studied the endometrium during and after 
menstruation, states that immediately after menstruation large gaps are 
seen in the superficial layer of the epithelium, and that during men- 



352 A TEXT-BOOK OF GYNECOLOGY 

stmation the entire epithelial layer is cast off, and that there is infiltra- 
tion and hemorrhage into the mucosa. This infiltration may extend 
through two thirds of the thickness of the latter. The blood clots 
which are fonnd within the uterus contain desquamated epithelium and 
glands. No true solution of continuity of the endometrium can be 
established. Von Kohlden has never been able to find the giant cells 
described by Leopold, or evidence of dilatation and tortuosity of the 
glands. The reproduction of epithelium begins de novo within the 
glands, not from islands of cells which were not cast off ; there is also a 
new formation of blood vessels. Lohlein (Ibid.) prefers this expression 
to either " membranous dysmenorrhoea " or " exfoliative endome- 
tritis/ 7 since dysmenorrhoea is a prominent symptom in only one half 
of the cases, and most observations show that there is no real inflamma- 
tory trouble. He believes that the membrane bears more of a resem- 
blance to a product of conception than to that of inflammation. 

The myometrium, or the muscularis of the uterus, consists of bands 
of decussating fibres arranged in different directions and in more or 
less definite concentric layers. Within the meshes of this fibrillation 
are to be found numerous nutrient vessels, branches of the uterine and 
ovarian arteries, with their accompanying veins. There are also freely 
interspersed within the muscularis numerous lymphatic vessels, which 
in the nongravid uterus are minute and generally closed, but which 
during pregnancy and immediately after parturition are greatly en- 
larged, their orifices communicating directly with the placental site. 
There are also numerous nerve filaments, derived, for the most part, 
from the sacral sympathetics. 

The Bacteria of the Uterus. — From just within the os externum 
upward, says Professor Sinclair, the female genital tract in health is 
free from bacteria. 

Confusion has arisen from methods of obtaining material for micro- 
scopic examination and cultivation experiments. Many observers have 
not succeeded in getting rid of the drop of mucus at the external os 
which should be considered as vaginal, and so have obtained results 
vitiated by the presence of vaginal bacteria in the material examined. 

Another trifling question which has received too much attention 
is the limit of the vagina in case of laceration of the cervix. The dis- 
cussion is mere logomachy. The part of the cervical canal which, by 
reason of laceration, is exposed to the vagina, must count as vagina 
from the point of view of bacteriological research. The part is well 
worthy of examination and comparison with the vagina and cervix 
proper, because of the change in the reaction of the secretion, which is 
alkaline within the lacerated portion; the difference in anatomic 
structure of the part which is cervical, and the inability of its lacerated 
muscle to completely contract, thus leaves the fissure in a state of 
stagnation. 

The external os uteri, then, thus defined, is the boundary line be- 
tween the vagina which in health swarms with all sorts of bacteria, and 



INFECTIONS OF THE UTERUS 353 

the canal of the cervix and body of the uterus which in health is abso- 
lutely free from germs. Upon this point at least there is almost abso- 
lute unanimity among the bacteriologists. 

Winter, who differed so egregiously from the majority with regard 
to vaginal bacteria, found, on examination of the healthy uterus with 
apparently healthy secretion, no bacteria in the cervix. When the 
cervical secretion was purulent he found bacteria in the cervical canal. 
The material on which he worked consisted of uteri obtained by ex- 
tirpation. He reached the following conclusions: (1) The healthy 
uterine cavity contains no micro-organisms; (2) the vicinity of the 
os internum in half the cases contains no bacteria; (3) the cervical 
secretion of every healthy woman contains numerous bacteria, and in 
pregnancy the bacteria, especially the bacilli, increase to a large extent. 
These statements coincide with those of many other German bacteriolo- 
gists, including Lomer and Bumm. Goenner, who made numerous 
observations, found bacteria in the cervix of pregnant women, but he 
failed to cultivate any. From this experience he draws conclusions 
against the theory of self-infection. 

Solowieff examined women suffering from gonorrhoea or from 
tuberculous disease. He found micro-organisms in the cervix in 
39 out of 45 women examined. In 7 cases he found streptococci and 
staphylococci. He concluded that bacteria are frequently found in 
chronic endometritis. Acute puerperal endometritis depends upon 
the presence of pyogenic bacteria. He reached the conclusion that 
the possibility of self-infection from the genital canal must be ad- 
mitted. 

Brandt (Zur Bacteriologie der Cavitas Corporis Uteri bei den Endo- 
metritiden) found, in 22 out of 25 cases, bacteria in the cavity of the 
uterus, and in 31 per cent of cases of endometritis, he found patho- 
genic organisms. Similar results of examinations have been published 
by many others. 

Menge published the results of some work in 1893. He always 
found the cervical canal free from germs except in cases of gonorrhoea. 
In these the gonococcus was always found in the cervical canal, and in 
many cases he obtained the bacterium in pure cultivation. In preg- 
nant women infected with gonorrhoea he always found the gonococcus 
and made pure cultivations from it. The secretion of the cervical 
canal was always alkaline. 

Stroganoff made observations on women during menstruation. 
After complete cleansing of the os externum he always found the canal 
free from bacteria. In elderly women, Stroganoff found the cervical 
canal free from bacteria in 50 per cent. When the uterus was prolapsed, 
bacteria were always found in small quantities in the cervical canal. 
In pregnant women under ordinary conditions he always found the 
canal free from bacteria. Stroganoff therefore concluded: (1) in 
normal circumstances the cervix contains no bacteria; (2) the normal 
cervical secretion possesses a bactericidal quality; (3) in the genital 
24 



354 A TEXT-BOOK OF GYNECOLOGY 

canal the os externum forms the dividing line between the germ-con- 
taining and the germ-free portions. 

Bnmm maintained in 1895, that in chronic endometritis of the 
body and cervix, in hyperplastic conditions resulting from inflamma- 
tion, as well as in the catarrhal form, no micro-organisms can as a rule 
be demonstrated to exist. The continuance of the disease of the 
mucosa does not depend upon the presence of micro-organisms. In a 
small number of cases there may be found in the secretion, but not in 
the tissues, of the diseased mucosa, a small number of bacteria includ- 
ing pyogenic cocci. These must usually be considered accidental ac- 
companiments of the endometritis. 

Wertheim says that gonorrhceal infection of the uterus always 
causes a purulent catarrhal endometritis, which, when it runs a chronic 
course, leads to hyperplastic-hypertrophic changes in the glands. The 
inflammation also extends frequently to the myometrium, and it 
is less marked in the cervix than in the cavum uteri. In about 
half the cases, the gonococcus was demonstrated in the secretion, 
and pure cultivations were obtained. No other bacteria were ever 
found when the gonococcus was present. Wertheim concludes that 
the external os presents no barrier whatever to invasion by the gono- 
coccus. 

Gottschalk and Immerwahr examined 60 cases and found bacteria, 
including Staphylococcus pyogenes, in the uterine canal in 65 per 
cent. They concluded that there was a secondary invasion of the 
endometrium by the staphylococcus in connection with a gonorrhceal 
infection which had run its course or become chronic. 

Menge made his investigations on 50 pregnant women. Of these, 
34 appeared to be without any disease whatever; in 16 there was 
something suspicious about the discharge. He found the gonococcus 
in 4 cases. In only 3 others were cultivations obtained, and these 
were white saprophytic masses which softened gelatine very slowly. 
He attributes their presence to filth from the vagina. Microscopic 
examination did not reveal the presence of cocci. Bacteria were seen 
with the microscope, but could not be cultivated. No bacteria which 
we know, that is to say, which can be cultivated by methods usually 
employed for aerobic and anaerobic germs in acid or alkaline media, 
or suitable for the gonococcus, could be discovered. 

The conclusion which Menge reaches is, consequently, that with the 
exception of the gonococcus no bacteria are found as a rule in the 
cervix of pregnant women. 

The material which Menge employed for his further work con- 
sisted of the extirpated uterus in 50 cases suited for operation. He 
was thus able to eliminate the errors arising from the necessity of 
obtaining secretion through the os uteri. The diseased conditions 
which called for operation had, however, led in many cases to the in- 
vasion of the cervix by bacteria which had only a modified interest for 
the gynecologist. 



INFECTIONS OF THE UTERUS 355 

In 20 cases Menge found nothing to suggest pathologic changes 
in the endometrium. 

In 30 cases there existed some turbid slimy discharge or other 
changes suggestive of gonorrhoeal infection. 

Of the 20 normal cases the cultivation material remained abso- 
lutely sterile in 16. In the remaining 4 cases only colonies of 
saprophytes were discovered. Vaginal bacteria were also found by 
other methods of cultivation, including an anaerobic streptococcus. 
In a large proportion of the suspicious cases the gonococcus was found. 
All the rest were considered to be vaginal bacteria. 

It was found in the course of examination of another series of uteri 
extirpated for various reasons, that the tubercle bacillus existed in the 
canal of the body and cervix when tuberculous disease affected the 
uterus or tubes. "When necrotic tissue was present, as in cancer of the 
vaginal portion of the uterus, innumerable saprophytic bacteria were 
found to flourish. 

Among the causes of the immunity from bacterial invasion of the 
cervical canal Professor Sinclair suggests: 

1. The difference in the reaction of the secretion, which keeps 
away from the cervix the facultative aerobes and pathogenic organisms 
which sometimes gain a footing in the vagina. 

2. The sudden change in the calibre of the canal. 

3. Increase of the muscular power of the walls of the canal. 

4. The downward stream of the secretion, which may add another 
mechanical influence. 

5. Some germicidal quality in the secretion — that is, in the leuco- 
cytes and in the fluid. 

6. The presence of the gonococcus when it has obtained access to 
the cervix. 

In reference to this last point there can be no doubt that the os 
externum and all the influences at work in the cervix present no 
obstacle to the advance of the gonococcus, and there is reason to believe 
that the presence of the gonococcus has some deterrent influence on the 
development of other bacteria. 

From what has now been said about the cervical canal, and a fortiori 
about the canal of the uterus as a whole, certain practical conclusions 
may be indicated without unpardonable irrelevancy. It must be obvi- 
ous that the cervical canal of the pregnant or parturient woman does 
not require disinfecting, and that any proceedings with that object are, 
to say the least, unnecessary. 

When the cervical canal is found to be the source of gonorrhoeal dis- 
charge in the woman in labour, disinfection is not possible. From the 
bacteriological standpoint, attempts to disinfect the cervix before or 
during labour are inadvisable. 

In women suffering from fibromyoma of the uterus, it used to be 
the custom during operation to dissect out or destroy by cautery the 
mucosa of the cervix, for fear of the stump in the intraperitoneal 



356 ' A TEXT-BOOK OF GYNECOLOGY 

operation becoming infected. The fear of infection at this point was 
also used as an argument in favour of pan-hysterectomy. It is obvi- 
ous from the teaching of bacteriology that all these operative details are 
unnecessary, and the argument as to pan-hysterectomy is all on the 
other side. 

Some interesting reflections arise in connection with this subject, 
in relation to the vicissitudes in the history of lamina ria tents. In 
Sinclair's opinion, tents are still the unrivalled means of dilating the 
nonpregnant uterus. The tents can be disinfected, the bouchon 
muqueux can be removed from the os externum, and then the canal 
is germ-free. Whence arise the exceptional cases of acute bacterial 
infection following the use of tents? Probably from some occult 
arrested condition of the gonococcus or from the life energies of bac- 
teria not yet discovered. 

We are now in a position to appreciate the dictum: The asepsis 
of the healthy genital canal in a pregnant woman begins at the introitus 
vagina, and the germ-free portion begins at the os externum. In the non- 
pregnant woman the cervical canal is also germ-free. 

It is hardly necessary to consider the cavity of the uterus as a dis- 
tinct part of the genital tract — a conclusion in which Professor Sin- 
clair is in accord with other advanced investigators. The result of 
such consideration is to emphasize the fact of immunity from organ- 
isms. All the work of bacteriologists who have obtained material by 
the curette or spoon, as applied to the cavity, may be set aside as 
vitiated by the mixing of material from the vagina. The most trust- 
worthy results have been obtained by examination of the uterus im- 
mediately after extirpation. Wertheim, whose work was pursued 
chiefly with the object of investigating the pathology of the sexual 
organs resulting from gonorrhceal infection, concluded that the cavity 
of the uterus contained either the gonococcus or no bacteria of any kind. 

Menge worked on the vast material of 118 uteri obtained by ex- 
tirpation, and the uterine canal in every case was immediately ex- 
amined for bacteria both by microscopic examination and by cul- 
tivation experiment. He devoted a good deal of time and trouble 
to the investigation of pyometra, which is almost always a result of 
bacterial invasion from malignant disease of the cervix, a work of 
supererogation as far as our subject is concerned. He might as well 
have given us the results of researches on the bacteria which infest 
the cancerous area itself and produce the foul smell of the discharge 
and other phenomena. 

On the ground of bacteriological researches Menge concluded that, 
neither in the secretion, nor in the tissues of the mucosa of the normal 
cavity of the body of the uterus, did bacteria exist which could be culti- 
vated in our usual media; and that, neither in the secretion, nor in the 
tissues of the mucosa of such uteri as showed in the corporeal mucosa 
the usual anatomic changes marking the individual forms of chronic 
endometritis with small-cell infiltration, did bacteria exist which could 



INFECTIONS OF THE UTERUS 357 

be cultivated according to any of our known methods. An exception 
must always be made as to the gonococcus and the tubercle bacillus. 

With regard to the tubercle bacillus it is a curious fact, to which 
Professor Sinclair calls attention, that though tuberculous disease 
exists either primarily or, more frequently, secondarily, in the cavity 
of the body, it seldom extends downward beyond the os internum, 
while in most cases of malignant disease of the cervix, the process 
comparatively seldom extends upward beyond the os internum. 

Individual cases of chronic endometritis stand probably in some 
causal relationship with the bacterial producers of puerperal infection 
and intoxication. The chronic endometritis of the nonpregnant 
woman is, however, not perpetuated by these micro-organisms. 

The cavity of the body of the uterus can be invaded by bacteria, 
or can for a considerable time harbour bacteria when it is injured, 
and bacteria are conveyed to it by direct inoculation, or when the 
defensive power of the cervix is inhibited by dilatation and the unfold- 
ing of its ruga?, either by new growths or by products of conception. 

Infections of the uterus may be appropriately classified as (a) 
mixed, and (b) specific. The mixed infections are those in which patho- 
genic bacteria of various classes are carried into the uterus and estab- 
lish inflammatory changes in the endometrium, or possibly subse- 
quently in the myometrium, or even in the perimetric structures. As 
will be seen when the pathology of these infections is considered, they 
are but rarely limited, at least in their sequent changes, to the lining 
membrane of the uterus; but through the utricular glands or the open 
lymph spaces the infection extends into the underlying muscular struc- 
ture; or, in the absence of absolute invasion by morbific micro-organ- 
isms, the secondary inflammatory phenomena, in view of the non- 
existence of a submucous connective tissue within the uterus, are 
manifested directly in the myometrium. Specific infections probably 
never exist as such if the term is construed to mean an infection due 
exclusively to a particular micro-organism; there are, however, cases 
in which a special bacterial organism — e. g., the Streptococcus pyogenes, 
the gonococcus, the Bacillus tuberculosis — exercise a predominating 
influence in producing pathologic changes, some of which are charac- 
teristic of the respective specific infection. It is probably not a demon- 
strable fact that any well-developed infection, however closely it may 
approximate the specific standard, ever exists except as a mixed infec- 
tion; yet, as in the cases of puerperal fever, gonorrhoea, tuberculosis, and 
especially in parasitic invasions — e. g., the echinococcus — the organism 
which exercises the controlling influence is so distinct, its characteris- 
tics are so well understood, its clinical manifestations are so definite, 
that the condition should be discussed as one of specific infection. 

Endometritis not depending upon specific micro-organisms for its 
causation, is the first and most frequent manifestation of ordinary 
mixed infections of the uterus. This term, etymologically, means an 
inflammation of the lining membrane of the uterus. There is serious 



358 A TEXT-BOOK OF GYNECOLOGY 

question whether this condition ever exists as a distinct clinical and 
pathologic entity — although Welch has stated that he has seen cases 
of genuine inflammation which can be called nothing but endometritis 
(American Obstetrical and Gynecological Journal). The connection 
between the endometrium and the myometrium being intimate, there 
being no intervening cellular structure and a common circulatory and 
lymphatic arrangement, it follows that inflammatory processes origi- 
nating in the endometrium are exceedingly prone to penetrate the 
muscularis. In those cases in which the inflammatory process is limited 
to the endometrium, such limitation probably exists simply in con- 
sequence of either the relatively slight virulence of the infectious 
elements, or the relatively short duration of the disease, or, a third 
possibility, because resolution has taken place in the deeper struc- 
tures. As a matter of fact, inflammatory exudations are generally 
observed in at least the superficial striae of the muscularis in practically 
all demonstrated cases of endometritis; and it is also true that in 
many cases of infections which must of necessity commence in the 
endometrium, the most essential pathologic changes are manifested 
in the parenchyma. It is to be concluded, therefore, that, patholog- 
ically speaking, infection of the endometrium implies an inflammatory 
disturbance, not alone of the mucosa, but also of the muscularis, and 
should, therefore, be designated as metritis. 

Backer denies that inflammation of the uterine mucous membrane 
exists as a separate condition. He believes it to be always associated 
with inflammation of the body of the uterus, and classifies it accord- 
ing to the French plan among the metritides. He divides metritis 
into the following groups: 

I. Uncomplicated infectious form: (a) catarrhal metritis; (b) gonor- 
rheal metritis. 

II. Complicated forms: (a) metritis post abortium; (b) metritis ex- 
foliativa; (c) metritis atrophicans. 

The diagnosis between the forms of Group II is easy, but the 
catarrhal is hard to distinguish from the gonorrhceal metritis. The pres- 
ence of gonococci is pathognomonic; in their absence the clinical his- 
tory must furnish the decisive details. The ordinary " catarrhal " 
metritis, such as results from excessive venery, onanism, and displace- 
ments of the uterus, is not an inflammation but simply a hyperemia 
which disappears when the cause is removed. 

The position assumed by Backer is that entertained by Pozzi and 
numerous other modern writers and pathologists; and it is the view 
upon which the discussion of infection will be based in this work. 
The terms endometritis and metritis will both be employed; the former, 
in particular, because it designates inflammation of the lining mem- 
brane of the uterus, to whatever extent the myometrium also may be 
involved. It is convenient for the purpose of designating inflammatory 
processes of the uterus since the most important phenomena of them 
are manifested upon its internal surface. 



INFECTIONS OF THE UTERUS 



359 



The ground upon which endometritis should be considered as a 
mixed infection is firmly established. Brandt found pathogenic 
organisms in 31 per cent of his cases of endometritis. Other ob- 
servers have found them in larger proportions of cases. The fact 
that Brandt's cases embraced both acute and chronic endometritis 
favours the doctrine of a bacterial causation in a much larger per- 
centage of the acute cases than was demonstrable; for, as is well 
known, bacteria within the uterus are relatively self-limiting, while 
the pathologic changes which they induce may continue. It follows 
from this, that in many cases of so-called chronic endometritis in 
which no bacteria can be demonstrated, the organisms have disap- 
peared by process of self-limitation. 

The pathologic changes that are induced by an acute mixed infec- 
tion are simply those characteristic of an acute inflammation in the 
mucous membrane. There is an immediate turgescence of the sub- 




Fig. 146. — " The stage of inflammatory exudation is speedily reached.'* — Eeed. 



epithelial capillaries, with a consequent overstimulation of glandular 
activity. The influence of the micro-organisms or of their toxines 
is such as to destroy, in some cases, the superficial epithelium in the 
more exposed area, while the germs themselves penetrate deeply into 
the mucous folds and the utricular follicles. The stage of inflamma- 
tory exudation is speedily reached (Fig. 146), and differs from the same 



360 A TEXT-BOOK OF GYNECOLOGY 

stage of inflammation in other tissues in the fact that there is no 
underlying submucous connective tissue to become the receptacle of 
the transuded liquor sanguinis and the migrated cellular elements 
of hematogenous origin. The exudation on the other hand takes 
place, at least, to an important degree, directly among the fibrillge 
of the myometrium. In exceptional cases, however, the exudation 
takes place more distinctly between the mucous membrane and the mus- 
cularis, with the result that the former is sometimes separated, in 
part at least, from the latter. It is this condition that occasions severe 
dysmenorrhea. Winter asserts that it is the origin, of some cases of 
dysmenorrhcea of the membranous variety. The sero-albuminous de- 
posit gives to stained sections an appearance more transparent than 
is observed in the normal mucous membrane. The changes incident 
to resolution now manifest themselves in the disappearance of the liquid 
elements of the exudate, and in the migration of the leucocytes toward 
the surface or into the minute lymphatics, until presently both the cel- 
lular and the noncellular elements of the exudation have disappeared. 
In many cases, however, in consequence of the peculiar structure of 
the endometrium, there exist within the deep follicles bacterial elements, 
which, modified in their virulence, perpetuate in a lesser degree 
the original inflammatory changes. The persistence of this irritation 
is sufficient, not only to prevent the resorption of the exuded elements, 
but to effect their continued deposition and organization. The result 
is a distinct hyperplasia, characterized by an increased thickness of 
the mucous membrane. A section of the mucosa reveals that it is 
of increased depth, while its cellular elements are not only relatively 
but absolutely increased in number. The leucocytes are found in 
some cases in large interstitial deposits, while the blood vessels them- 
selves show but slight thickening of their walls. As a result of these 
interstitial deposits increased pressure is exercised upon the glands 
which now seem smaller and relatively fewer in number. In this stage, 
bacterial elements have generally disappeared from the secretion, the 
withdrawal of their influence resulting in the more or less speedy super- 
vention of the next stage of the process; this is characterized by 
an absorption, to a certain degree, of the remaining free elements 
of exudation, but without any material diminution in the number 
or size of the hyperplastic products. These, on the contrary, con- 
tinue to exercise pressure upon the already compressed glands which 
now undergo atrophy; or, as may happen, an efferent duct may be- 
come occluded and the underlying follicle thus become converted 
into a retention cyst. Some of the glands, instead of being at right 
angles to the mucous surface, as under normal conditions, become 
oblique, and the stroma is characterized by increased density, and, on 
section, shows cells that have become elongated and arranged in bun- 
dles and fasciculi. The changes that are now presented are very much 
like those observable in the senile uterus. In these cases there is 
generally diffuse sclerosis of the muscularis. 



INFECTIONS OF THE UTERUS 361 

The most ordinary, and more or less persistent, change following 
an acute infection of the uterus is that of glandular hypertrophic endo- 
metritis. In this form the cellular changes are restricted chiefly to 
the epithelium, the cells of which undergo, not only hypertrophic, but 
hyperplastic changes. The result is essentially one of increased 
glandular development, with corresponding increase of functional capa- 
city. The glands seem to be increased in size and number and to 
be studded more closely together than in normal conditions. The 
exuberance of epithelial cell growth results in an apparent thickening 
of the endometrium, which now appears to be arranged in slight folds, 
on the apices of which, more distinctly than elsewhere, the cell de- 
velopment seems to be luxuriant. On section, the mucous glands, 
instead of being straight tubules projecting downward into the stroma, 
are found to be tortuous, or, in other cases to show simple devia- 
tion in axis. On cross section their calibres are found to be widened, 
their lumen being largely occupied by the exuberant cell growth. In 
this class of cases the lumen of the mucous gland often becomes so 
distended with newly formed epithelial elements that the latter project 
from the ostium and appear upon the surface with a sort of granu- 
lation. In the more distinctly hyperplastic varieties, there seems to 
be not only an increase in the number of the tissue elements, but a 
multiplication of the glands themselves. These glands increase in size 
and number, and sometimes show a marked increase in the interglandu- 
lar stroma. The exuberant cell growth in these cases results in a 
thickening of the mucous membrane, the surface of which presents a 
fungous appearance. It is for this reason that the condition is some- 
times called fungous endometritis. As the epithelial cells develop 
from the matrix there is demonstrable a certain proliferation of the 
sanguiferous capillaries to give them support. The cell growth is, 
however, so active that it gets beyond the influence of the nutrient 
supply and undergoes fatty degeneration. When this occurs, the ter- 
minal filaments of the newly proliferated vessels are exposed, and 
hemorrhage results. 

It is sometimes important to distinguish areas of glandular hyper- 
trophy occurring upon a limited area of everted cervical membrane, 
from syphilitic infection. In the first place the primary syphilitic sore 
of the portio vaginalis is rare, and when it occurs it is manifested 
by a distinct erosion, ulcerative, with sharply defined borders. It 
is in nearly every case associated with induration of (1) the intra- 
pelvic lymphatics, and later (2) those in the inguinal regions. Chan- 
croids are liable to be overlooked, as they are generally painless and, 
aside from an offensive discharge, produce no symptoms. 

The causes of endometritis may be summarized in the general word 
infection. There are, however, numerous conditions which seem to 
contribute to this infection. As has been shown by Sinclair, the 
uterine cavity from the os externum to the fundus is normally free from 
bacteria. When infection occurs above the external os it must be as 



362 A TEXT-BOOK OF GYNECOLOGY 

the result of the carriage thither of the infectious element. The use 
of instruments to produce abortion, and the employment of the uterine 
sound for more legitimate purposes, may be held responsible for a large 
number of cases. The use of an unclean speculum is a reasonable 
explanation of the infection of the upper portion of the vagina, whence 
the infection may extend by progressive invasion of the mucous sur- 
faces to the endometrium. Pessaries, for the most part unclean and 
stinking things, are to be looked upon with more than suspicion. The 
use of an unclean syringe nozzle is dangerous. There are certain phys- 
ical conditions of the uterus that are undoubtedly predisposing causes 
of infection. Laceration of the cervix, by exposing a portion of the 
endocervium to the infectious elements that abound in the vagina, may 
pave the way for a more general involvement. Schultze has called 
attention to the influence of a chronic dilatation of the cervix in favour- 
ing the introduction of morbific agencies into the uterine cavity. Pro- 
lapsus of the uterus, when complete, is generally associated with more 
or less infection of the endometrium. Uterine displacements in gen- 
eral may be looked upon as contributory influences in producing the 
pathologic states which are found in patients with associated demon- 
strable infection. 

Neoplasms of the uterus, particularly when they have become the 
seat of retrogressive changes, are a source of infection. Abel and Lan- 
don, after making numerous careful microscopic studies, arrived at 
the conclusion that in cases of cancer of the cervix the corporeal endo- 
metrium undergoes marked changes — especially of an inflammatory 
character. 

Acute infectious diseases have been looked upon as causes of endo- 
metritis. Massin of St. Petersburg (Archiv fur GynaJcologie) made an 
effort to settle this question by conducting a series of experiments upon 
eighteen cases. Of these, twelve were cases of relapsing fever, two of 
pneumonia, two of enteric fever, one of dysentery, and one case of acute 
general peritonitis of unknown causation. The uterus, with the adnexa, 
was removed at the autopsy and placed in Miiller's fluid, and allowed to 
remain therein from a month to six weeks. Sections were made from 
different portions of the uterine walls, including the os internum and 
cervix. They were first kept in alcohol (70 per cent), then placed 
in absolute alcohol for one week, and then in photoxylin solution. The 
sections were stained with borocarmine, picrocarmine, eosin, and 
methylene blue. From an examination of these specimens the follow- 
ing conclusions were arrived at: " The mucosa is affected in all of these 
acute infectious diseases, as are the glands, the vessels, and the uterine 
muscular fibres. Firstly, they are all markedly injected. The injec- 
tion may be marked in one portion of the mucous membrane, or, as was 
usually the case, may affect the entire mucous membrane. The in- 
creased size of the vessels was especially noted in the small veins and 
capillaries. The arteries were empty, and in only a few cases did they 
contain formed blood elements. In many cases the dilatation was so 



INFECTIONS OF THE UTERUS 363 

great as to cause a rupture of the vessels, and consequently hemorrhages 
into the mucous membrane and between the muscular layers. These 
ecchymoses occurred in cases irrespective of the age of the patients. 
The most marked cases of dilatation and rupture were those in which 
the disease had been continuous, as in the cases of pneumonia and 
enteric fever, whereas in the cases of relapsing fever hemorrhages were 
only found in half of the cases. Next, in reference to the glands. The 
epithelium lining these was always swollen and cloudy, having rounded 
edges; the cells were coloured with difficulty. The epithelial cells 
secreted more mucus than normally. In some cases the glands were 
markedly enlarged. In many cases the epithelium was detached from 
the glandular tissue and lay in irregular masses in the glandular cavi- 
ties. The membrana propria of the glands and the surrounding layer 
of spindle-shaped cells were well marked in nearly all of the cases. 
We frequently observed new-formed granular elements, which were 
arranged around the glands in the form of a belt. The muscular layer 
of the uterus did not seem to be much affected by the disease. As 
stated above, the vessels in the muscular layer were injected. The 
changes which we observed represent a parenchymatous and interstitial 
inflammation of the mucous membrane and an interstitial inflammation 
of the muscular layer. Furthermore, in all of the cases a condition 
was observed which can be termed a hemorrhagic endometritis. We 
naturally conclude, after having made these experiments, that the 
endometritis undergoes three processes: 1. Increased amount of blood 
to the uterus, venous stasis, and inflammation of the vessels; 2. Granu- 
lar inflammation; 3. Diffuse spreading of this inflammation. In our 
experiments we were unable to ascertain whether micro-organisms were 
present or not. We must, therefore, consider acute infectious diseases 
as important factors in the causation of uterine diseases, so that when 
we consider the etiology of acute and chronic endometritis we must 
always think of the possibility of the affection being the result of an 
acute infectious disease." 

The symptoms of endometritis vary somewhat according to the 
pathologic changes upon which they depend. In the simple infec- 
tions of the endometrium involving only the superficial epithelium 
and the mucous follicles, there occurs a discharge ordinarily designated 
as uterine leucorrhcea. This discharge is generally clear and viscid 
and is occasionally stained with blood. It is sometimes of a distinctly 
muco-purulent character. Schultze, recognising the fact that purulent 
elements may be so slight in the uterine discharge as to escape detec- 
tion, advises the use of a glycerine tampon for diagnostic purposes. The 
tampon should be removed by the surgeon, who should carefully inspect 
it and thereby ascertain with accuracy the presence or absence of puru- 
lent elements. In cases of long standing, frequent hemorrhages, oc- 
curring either in connection with menstruation or during the inter- 
menstrual period, are to be construed as evidences of fungous degen- 
eration of the endometrium. There may or may not be dysmenorrhcea, 



364 A TEXT-BOOK OF GYNECOLOGY 

and the uterus may or may not be enlarged. The cervix in the major- 
ity of cases is, however, the seat of more or less engorgement or infiltra- 
tion, or may even be cedematous. In some cases the uterus may be 
painful, a condition which Sneguireff of Moscow designates as endome- 
tritis dolorosa. Sensibility of this character is generally more marked 
at the fundus. 

The diagnosis depends not only upon the symptomatology, but 
especially upon the demonstration by microscopic and bacteriological 
examination of bacterial elements in the uterine secretion. If the 
endometrium is everted at the cervix and presents a granular appear- 
ance the case is one of glandular hypertrophy. If hemorrhages are 
present there exists a strong suspicion of endometritis fungosa. It 
should be remembered, however, that hemorrhage is a conspicious 
symptom of various malignant processes, not only of the cervix but of 
the corpus uteri. (See Symptoms of Malignant Neoplasms of the 
Uterus). In view of these facts and under these circumstances it is 
imperative that the uterine cavity be explored. The cervix should be 
dilated. This is done preferably by some of the mechanical dilators, 
such as Palmer's convenient device; or, as preferred by Sinclair, a 
carefully sterilized laminaria tent may be then employed. The chief 
objection to the latter is the time and discomfort involved in its use. 
Dilatation should be carried to a degree that will admit of the easy 
introduction of a curette or of a curette forceps. Either one or the 
other of these instruments should then be inserted and by gentle 
scraping some of the intrauterine tissue should be removed. This 
should be carefully preserved and examined microscopically. Gessner 
(Zeitschrift fur GeburtsMilfe u. Gynakologie) in a careful discussion of 
the technique of exploratory curettage states that anaesthesia is useful 
although not indispensable. The dilatation is to be carried to a degree 
that will admit of the introduction not only of the curette, but subse- 
quently of an irrigation catheter. A sharp curette is to be employed 
and the whole interior of the uterus must be carefully scraped and every 
fragment so removed must be examined under the microscope. Unless 
this precaution is taken, evidences of malignancy which may be derived 
from a very limited area may escape detection. Sanger recommends 
that the uterine canal be dilated by means of laminaria tents until not 
only a curette, but also the finger, can be introduced into the uterine 
cavity. He states that in those affections of the corpus in which malig- 
nancy is always to be suspected, the use of the curette is superior to 
simple palpation, but palpation with curettage and microscopic exam- 
inations of any debris that may be removed will give more information 
than the two latter only. While Sanger insists upon this technique in 
cases of abortion and of myomata of the corpus uteri, he recognises in 
digitation a valuable diagnostic expedient in certain enlargements of 
the uterus associated with involvement of the endometrium. Gessner, 
in speaking of the diagnostic value of exploratory curettage, states 
that in the Frauenklinik of the University of Berlin, a diagnosis of 



INFECTIONS OF THE UTERUS 365 

malignant disease of the corpus uteri had been made and the organ 
had been extirpated in fifty-eight cases during a few years. In eleven, 
carcinoma could be distinctly felt through the dilated cervix; in three 
others in which the finger could reach the new growth the disease was 
found to be sarcoma. In forty-one cases, however, the diagnosis was 
made, not by digitation, but by exploratory curettage. He looks upon 
the latter as the more valuable expedient. When the scrapings are 
examined the diagnosis will be established by their resemblance to the 
histopathologic appearances already described. 

The treatment of endometritis must depend somewhat upon the 
particular pathologic condition that may be presented at the time. In 
the simple catarrhal forms, in which the most annoying symptom is a 
persistent leucorrhcea, reliance is often placed upon topical remedies. 
As has been shown in the discussion of the pathology of this condition, 
there exist such organic changes that any results that may follow the 
use of local medication must be at best slow and uncertain. It may be 
stated as a rule that intrauterine medication for catarrhal conditions 
is unsatisfactory. There are patients, however, who prefer to be 
treated locally for a long time rather than to submit for a few days to 
anything suggestive of surgical intervention. In these cases treatment 
should consist in the use of bactericidal agents. These should be so 
applied that the entire mucous surface should be subjected to their 
influence; for, if a portion of the mucous surface remains untreated, 
and consequently infected, it becomes the focus for the reinfection of 
the entire structure. Another principle of equal importance is, that 
an intrauterine application of a bactericidal character should be 
repeated or maintained for several days, so that, not only the bacteria 
themselves, but their spores also will be destroyed. There is probably 
nothing in the whole range of gynecological therapeutics that is so 
futile, not to say farcical, as the repeated applications to the cervical 
membrane of various medicaments of undetermined antiseptic value, 
and many of them of unknown ingredients. As a rule these applica- 
tions are made to a canal bathed with tenacious mucus, which of itself 
constitutes an efficient protective for the underlying micro-organisms. 
Topical treatment, to be effective, must be brought into direct contact 
with the micro-organisms. These, as already described, are hidden away 
within the epithelial folds or deep down in the mucous follicles. The 
tissues themselves, both epithelial and subepithelial, are more or less 
hypertrophied; an agent, therefore, which will be effective must 
modify this histologic state. Most practitioners have, therefore, aban- 
doned the use of nonescharotic agents. Those that are employed, 
however, are not viciously destructive of the tissues like nitric acid 
or sulphuric acid, or pure formalin. Feed's method of treating these 
cases is as follows: The cervical canal is dilated, if necessary, to a very 
slight degree by means of a Nott or other small dilator. The posterior 
lip of the cervix is seized with a volsella or the serrated cervix forceps of 
Dumont-Lelois and held by slight downward traction. The uterine 



366 A TEXT-BOOK OF GYNECOLOGY 

cavity is then packed with a very slender ribbon of dry sterilized gauze; 
this is immediately withdrawn, bringing with it all the mucus from 
the endometrial surface. If a first packing is not satisfactory for this 
purpose, a second may be utilized. After the mucous surfaces have 
thus been carefully cleansed, the uterine cavity is again packed with 
a slender ribbon of gauze saturated with 98-per-cent carbolic acid. 
This is left in situ. In applying the carbolic acid it is important to 
avoid bringing it in contact with the integument of the mucous mem- 
brane of the vagina; but if this accident should happen, the place 
should be immediately touched with pure alcohol, which will neutralize 
the carbolic acid. A tampon of glycerine or of boroglyceride is applied 
and the patient is permitted to go home, returning in forty-eight 
hours for a repetition of the treatment. Three or four applications of 
this kind, made at lengthening intervals during ten days, are generally 
sufficient to cure an ordinary case of catarrhal endometritis. The 
treatment, contrary to usual theoretic preconceptions, is not particu- 
larly painful and never requires an anaesthetic. The destruction of 
epithelium from these repeated applications is not sufficient to inter- 
fere with its speedy reproduction. Cases have been reported in which 
cures have been effected by the introduction into the uterine cavity of 
a piece of lunar caustic, which was permitted to dissolve in situ. The 
uterine cavity has been packed with boric acid and with iodoform, 
both of which have some bactericidal properties. Canquoin has re- 
ported successes from the intrauterine application of a paste the 
essential ingredient of which is the chloride of zinc. It is prepared 
in the form of a pencil and is introduced into the uterus; Pichevin, 
Emmet, Schroder, Martin, Munde, Jacobs, and others, have reported 
adversely on its use, and it seems to have been discontinued. As an 
escharotic agent, the chloride of zinc is vastly more destructive 
than even the silver nitrate, the use of which has been very generally 
abandoned. 

Sneguireff recommended the action of steam upon the inner surface 
of the uterus as a means of arresting intrauterine hemorrhage, and it 
has been quite extensively employed, especially in Russia. Its applica- 
tion requires a steam generator with a safety valve and with a central 
opening for the insertion of a thermometer, the generator being con- 
nected by rubber tubing with a metal catheter of necessary length for 
intrauterine application. The temperature should be kept between 100° 
and 110° C. (212° F. to 230° F.). A Fritsch uterine irrigator may be 
used for the application of the steam. The patient is placed in the 
lithotomy position, and a short cylindrical speculum of some noncon- 
ducting material, such as celluloid or hard rubber, or preferably wood, 
is inserted. A catheter is then inserted and the steam is turned on. 
The instrument should be encircled with gauze, or provided with a 
nonconducting handle, to avoid burning the hands of the operator. 
The patient should remain in bed for a few days. There is generally 
considerable reaction with pronounced perimetric irritation. It has 



INFECTIONS OF THE UTERUS 367 

been recommended by Pincus for senile endometritis with profuse 
hemorrhage or leucorrheea; where irregular hemorrhages are associ- 
ated with subinvolution of the uterus; for diffuse myomata; for 
hyperplastic or catarrhal endometritis; and for gonorrhceal and strep- 
tococcous infections of the uterus. It must not be used in the presence 
of diseased adnexa or in cases of stricture of the cervical canal, while 
it is not advised in polypoid myomata. This method is spoken of as 
vaporization, but it is really a cauterization with extensive destruction 
of tissue. It is possible that the principle may survive, although the 
present technique seems to be defective. The use of superheated 
steam destroys tissue to a depth that is dangerous. Baruch reports a 
case of atrophy of the uterus with occlusion of the cervical canal and 
apparently of the whole uterine cavity, following vaporization in a 
woman only twenty-seven years old. This condition amounting to the 
practical destruction of the uterus was induced by a single intrauterine 
application of steam for the purpose of checking puerperal hemorrhage, 
an object which was speedily accomplished. Von Guerard (Central- 
Matt fur Gynal'ologie) reports the case of a woman who had persistent 
hemorrhages following delivery, with evidences of subinvolution of 
the uterus and fungous degeneration of the endometrium. Atmocau- 
sis, as this method of vaporization is called, was employed. There was 
a cessation of the menses following the operation, but at the menstrual 
periods unendurable pains were felt, becoming intensified as time went 
on. The uterine cavity was so obliterated by the steam jet that the 
sound entered it for about 2 centimetres only. Von Guerard was 
forced to relieve the patient by a total hysterectomy, from which she 
recovered. In commenting upon the case, he insists that atmocausis 
was absolutely contraindicated before the menopause. Schick, of 
Prague (C entraMatt fiir Gynakologie), recognising the valuable prop- 
erty of heat for antiseptic and hemostatic purposes and as an escharotic 
agent, has endeavoured to secure its desired effect by the use, not of 
superheated steam, but of boiling water. He kept up the irrigation 
for half a minute, only the vagina and vulva being protected by con- 
stant irrigation of ice-cold water. Of the four cases in which he tried 
it three were successful. While this treatment may be of great value, 
its employment is certainly associated with great danger, and it is 
mentioned in this connection only with the hope that the valuable 
principle which it embodies may find safe exemplification in more re- 
fined methods. 

It may be stated, as a rule to which there are no exceptions, that 
in all cases of infection of the uterus in which the condition has 
assumed the chronic form with associated histologic changes, the 
topical application of any medicament, escharotic or otherwise, is less 
satisfactory than curettage followed by appropriate antiseptic treat- 
ment. 



368 



A TEXT-BOOK OF GYNECOLOGY 



Curettage of the Uterui 



Instruments for Dilatation of the 

Catheters, glass (Fig. 147) 1 

Catheter, irrigating two-way, small. . . 1 
Curette, sharp (Sims's modified) 1 

Martin's blunt, double 1 

Martin's sharp (Fig. 148) 1 

Dilators, Palmer's medium. 

Hegar's, 4 sizes (Fig. 149). 

Goodell-Ellinger. 
Forceps, Bozeman's long dressing (Fig. 
150) 1 

Rat-tooth 1 



Cervix and Curetting of the Uterus 

Forceps, bullet 2 

Serrated cervix forceps of Dumont- 

Leloir (Fig. 151) 1 

Nozzle, Edebohls's 

Packer, vaginal 



1 

1 

Sound, uterine 1 

Speculum, Jones's (Fig. 152) 1 

Sims's small 1 

Simon's, with handles and four blades 

(Fig. 153) 1 

Tenacula (Fig. 154). 




• 



In those varieties of intrauterine infection resulting in the develop- 
ment of fungous granulations with associated hemorrhage, intra- 
uterine medication of whatever sort is futile. The only 
available remedy consists in the removal of the adventitious 
tissue. Patients who are the victims of hemorrhage, and 
are consequently greatly reduced in strength, are generally 
less persistent in urging objection to the slight surgical pro- 
cedure of curettage. This, with associated antiseptic meas- 
ures, is distinctly the most valuable means of treating infec- 
tions either acute or chronic, either mixed or specific, of the 
endometrium; while if not followed by antiseptic measures 
it is a worthless and dangerous expedient. The 
uterine curette, according to Pozzi, was invented by 
Kecamier, after which it fell into discredit. J. 
Marion Sims did much to re-establish the instru- 
ment in favour, while Thomas Roux and the elder 
Martin have been instrumental in defining its uses 
and limitations. The curettes, as now found, vary 
in size and form; some of them are dull wire loops, 
bent at various angles; others are spoon-shaped, 

\some with dull and some with sharp edges; some 
are steel loops with sharp edges, while others, like 
that recently invented by Gau (Fig. 144), are pro- ^ IG - U8 - 
vided with a safety end, and yet can be used as 
either a sharp or a dull instrument. All of them are 
found illustrated in the instrument makers' cata- 
logues. The object of the curette is to remove ad- 
ventitious tissue from the uterine cavity or cervix. The method of its 
employment does not differ from that already described in connection 
with exploratory curettage as a means of diagnosis in endometritis 
(ante). As a matter of fact, curettage, whether undertaken for diagnos- 
tic or other purposes, should always be conducted with the same ante- 
cedent and sequent precautions. The same rigorous antisepsis should 
precede the operation, the interior of the uterus should be treated in 



Fig. 147 



catheter. 
— Kobb. 



Martin'i 

sharp 

curette. 

— Kobb. 



INFECTIONS OP THE UTERUS 



369 



precisely the same way, and the operation itself should be just as ex- 
tensive when undertaken for diagnostic as for other purposes. It may 
be accepted as an axiom of practice that the existence of any condi- 
tion demanding the use of a curette can be determined by macro- 
scopic appearances; while the more refined diagnosis may be based 
upon subsequent examination of the scrapings. 

The first contraindication of curettage is nonexperience in uterine 
surgery on the part of the operator. There is probably no manipula- 




Fig. 149. — Hegar's dilator. — Kobb. 




tion in surgery for the proper practice of which more dexterity, more 
deftness, or more of that judgment which depends on the tactus eru- 
ditus, is demanded than curettage. Among other contraindications, 
summarized by Currier (International Journal of Surgery), are igno- 
rance on the part of the operator of the exact limits and outline of 
the uterine cavity; the presence of the menstrual flow; extreme dis- 
placements of the uterus; and acute infectious diseases of the uterine 
appendages. Polk (New Yor~k Journal of Gynecology and Obstetrics) 
takes the ground that curettage is an eligible operation in cases of 
chronic metritis associated with salpingitis, asserting that, when prop- 




Fig. 150. — Bozeman's long dressing forceps. — Kobb. 



erly done, it affords much-needed depletion to the uterus and is not 
followed by peritonitis or acute salpingitis; and in support of his 
statement presents a tabulated list of forty cases giving the maximum 
diurnal temperature for eleven days following the operation. It is 
certainly a gratifying exhibit showing but trifling and evanescent 
reaction, and that only in a few cases. But gratifying as these facts 
are, they can not be accepted as demonstrating the safety of curettage 
in the presence of inflammatory conditions, whether acute or chronic, 
in which pus, although in undetectable quantities, is liable to exist 
25 



370 



A TEXT-BOOK OF GYNECOLOGY 



in the uterine appendages. The necessary traction and vigorous 
manipulation essential to a thorough curettage is liable to produce 
cleavages in adhesions and consequently to liberate previously con- 
fined pus. 

Objection has been urged against the use of the sharp curette upon 
the ground that it destroys the epithelium which is replaced by cica- 
tricial tissue. This objection is not tenable unless the operation 
amounts to a practical endometrectomy involving the complete re- 
moval of the basis membrane of the endometri- 
um. As has been shown by Von Kohlden and 
others, there occurs physiologically in con- 
nection with the menstruation a periodical 
loss of epithelium. This 
physiologic function may 
be carried to the patho- 
logical degree involving 
the shedding of the en- 
tire membrane. (See 
Membranous Dysmenor- 
rhea). When this oc- 
curs, however, the membrane 
is again speedily reproduced. 
Bossi has studied the repro- 
duction of the mucous mem- 
brane of the uterus, following 
its apparent complete destruc- 
tion by Canquoin's paste of the 
chloride of zinc. From his ob- 
servations and a more or less 
thorough investigation of the 
question, he has arrived at the 
following conclusions (Nou- 
velles arcliivzs d'obstetrique et de 
gynecologie, December, 1891): 
1. The mucous membrane of 
the uterine body in the bitch, 
abraded by free cuts of the bis- 
toury extending through its 
whole thickness, is reproduced 
in its integrity, that is to say, with a formation of true glands. 2. Re- 
production takes place slowly, and sometimes, by reason of conditions 
not well determined, is subject to considerable retardation. 3. The 
covering epithelium, which primarily extends over the wounded sur- 
face, derives its small glands from the borders of the cut. 4. The 
newly formed glandules derive from the proliferation of cells a new 
covering epithelium when it has acquired the cylindrical form. 

As a final word on curettage in the treatment of endometritis, let 





Fig. 151. — Serrated cervix for 
ceps of Dumont-Leloir. 



Fig. 152. 
Jones's speculum. 



INFECTIONS OF THE UTERUS 



371 



it be said that the mere scraping away of inflammatory products is 
curative to that extent and to that extent alone; that if the treat- 
ment; stops at that point it will be worthless; that curettage is not 
necessary in the many cases, even to remove these inflammatory prod- 
ucts; that its value consists in removing those tissue elements which 
serve as hiding places for the morbific micro-organisms; and, finally, 
that the essential element of the treatment consists in the thorough 




<H 



Fig. 153. — Simon's speculum. — Robb. 



Fig. 154.— Tenacula, — Robb. 



application of antiseptic agencies to the denuded endometrial surface. 
Curettage is, therefore, but a part, although a very important part, 
of a plan of treatment which has for its object, not alone the re- 
moval of pathologic products, but the destruction of the causative 
bacteria and their spores. 



CHAPTEE XXVII 

INFECTIONS OF THE UTERUS (Continued) 

Specific: Gronococcous infection (gonorrhoea) — Streptococcous infection (puerperal 
fever) — Tuberculous infection (tuberculosis): of the cervix: of the corpus — 
Syphilitic infection (syphilis) — Echinococcous infection (hydatids). 

Gonococcous infection of the uterus is simply an upward extension 
of gonorrhoea from the vagina. This rarely occurs spontaneously, be- 
cause of the resistance offered, first, by the mechanical arrangement 
of the vagina, and next, by its secretions and its normal bacteria, 
notably, the acid-secreting bacillus of Doderlein. (See Gonorrhoea of 
the External Genitalia.) Extension to the uterus in the majority of 
cases is the result of mechanical intervention in some form. As 
pointed out by Eosenwasser, it often results from meddlesome treat- 
ment of the disease when limited to the vulva. Some physicians pro- 
ceed upon the mistaken theory that the vagina is the primary seat 
of infection of gonorrhoea in woman, and begin at once to treat 
that canal with mistaken vigour. The ordinary result of such inter- 
ference is to establish the very condition which it is desired to 
overcome. It must be admitted, however, that in the majority of 
cases, the patient herself, rather than her physician, is responsible for 
the extension of the infection. The practically universal use of the 
vaginal douche results in these cases in mischievous complications. 

Schultze investigated two hundred cases with the result that he 
disproved the accuracy of Broese's opinion that the uterus is infected in 
every case of gonorrhoea in women. Schultze further concluded that 
gonorrhoea is infectious only until the gonococci have disappeared from 
the secretion, whether the latter is vitreous or purulent; he found 
that when the cervical secretion contains no gonococci there are none 
in the secretion from the cavity of the uterus. The secretion was 
purulent in a trifle over 50 per cent of the cases, while in the rest 
it was vitreous and merely turbid, the latter conditions not excluding 
the existence of gonococci. The gradual upper extension of the in- 
fection was indicated by the fact that even when the cervix was 
involved, the uterus showed contamination in only 38 per cent of 
the cases. The adnexa suffered in 38 per cent of those with cervical 
gonorrhoea, and in 45 per cent when the uterus also was infected. 
Van Schaick (New York Medical Journal) made a study of gonorrhoea 
372 



INFECTIONS OF THE UTERUS 373 

in married women and found gonococci existing as at least complicating 
causes of leucorrhcea which apparently depended upon cervical lacera- 
tions. 

The symptoms of gonococcous infection of the uterus do not differ 
materially from those which have been described in connection with 
the recognised mixed infections. (See Endometritis.) The diagnosis, 
however, depends upon the demonstrated existence of the gonococcus; 
with the gonococcus present there is gonorrhoea; without it there is 
no gonorrhoea. Neisser observes that many cases of undoubted gon- 
orrhoea would escape recognition if clinical evidences, alone, were re- 
lied upon. The gonococcus is not always easily found. Van Schaick, 
in a careful examination of sixty-five women, found gonococci seven- 
teen times, or in 26 per cent of the cases. Nineteen women were 
examined twice, and in three, gonococci were found at the second 
examination. Thirty-two were examined three times, and in three 
of these the third examination revealed the presence of the micro- 
organisms. It is of importance in this connection to note the con- 
clusion of Broese and Schiller (Berliner Tclinische ^Yocllenscllrift) that 
the intercellular arrangement of gonococci is not to be recognised 
as pathognomonic of acute gonorrhoea, since they have repeatedly found 
them outside the cells. The diagnosis of chronic gonorrhoea, these 
observers contend, may be based upon the characteristic shape and size 
of the gonococci, and upon their reaction to the Pick-Jacobson method 
of staining. The history of a previous acute attack of vulvar and 
urethral gonorrhoea, particularly if treated with douches and tampons, 
is a clinical factor of conclusive diagnostic importance. In the puer- 
peral state, gonococcous infection of the uterus is manifested by an 
increase in the volume of the lochial discharge, which becomes puru- 
lent but not necessarily offensive. The purulent character of the 
lochia is observed as early as the fourth day after delivery. Kronig 
has observed a temperature of 104° F., or more, resulting from these 
germs in the uterus. The occurrence of ophthalmia neonatorum in 
the child is a confirmatory evidence of gonorrhceal infection. The 
final diagnosis, however, depends upon the demonstration of the char- 
acteristic micro-organisms in the lochia. 

The pathology of gonorrhceal infection of the uterus has but few 
points at variance from that of the other infections. It would seem 
that the micro-organism reaches the cervical mucosa in a condition 
of reduced virulence, but sufficiently potent to cause the usual in- 
flammatory phenomena. Its behaviour in the endometrium does not 
differ materially from that in other mucous membranes. In the acute 
form the micro-organisms may or may not penetrate the cells, and, 
as has been already stated, their extracellular existence is not in- 
consistent with true gonorrhceal infection. If the infection is received 
during the course of pregnancy it is liable to cause miscarriage, with 
a probable upward extension of the disease to the Fallopian tubes, as 
has been demonstrated by Wertheim. Madleur (C 'entralblatt fur Gynd- 



374 A TEXT-BOOK OF GYNECOLOGY 

kologie) has shown that in the puerperal state gonococci may pene- 
trate the muscnlaris and cause parenchymatous suppuration; and that 
from this point the infection may reach the system through the lymph 
channels and cause arthritis, endocarditis, etc. In these cases, how- 
ever, the infection is probably associated with, if not dominated by, 
Streptococcus pyogenes. Leleneff (Wiener klinisclie W ochenschrift) has 
confirmed the observations of Madleur, as he has demonstrated the 
gonococci between the bundles of muscular fibres. He states, in addi- 
tion, that the destructive action of the gonococci upon cellular proto- 
plasm causes the latter to degenerate and liquefy, leaving only a 
feebly staining vacuolated nucleus. In view of the fact that these 
changes have been observed alike in those cells which contain the 
gonococci and those which do not, it is assumed that the destructive 
action must be due to some toxines produced by the gonococci. The 
widely credited power of gonococci to penetrate the leucocytes is con- 
firmed, while it is also demonstrated, contrary to previous opinions, that 
they invade squamous as well as columnar epithelium, and that it is 
by virtue of this fact that they find their way into the deep struc- 
tures of the uterus. 

The treatment of the acute stage should be conducted with refer- 
ence to avoiding unnecessary diffusion of the infection. As has been 
shown by observations already alluded to, infection may exist in the 
cervical canal without its extension to the corpus uteri. This fact 
is to be held in mind in the adoption of treatment. The cervical 
canal should be thoroughly cleansed and treated with protargol, a 
proteid compound of silver. Neisser looks upon this agent as an effi- 
cient antigonorrhceal remedy, which, if employed at an early period, 
exerts a prompt and favourable influence upon the course of the 
disease. In most cases it arrests all acute manifestations, causing 
rapid disappearance of the secretion and the gonococci, and prevent- 
ing the extension of the disease. Salochin has used this remedy in 
a 5-per-cent solution applied through a speculum to the cervical 
canal. The vagina was treated with a 2-per-cent solution, and a 
tampon moistened with it was left in position. The solution made 
by Colombeni is as follows: Ten grammes of protargol are placed in 
a small mortar to which are added 5 cubic centimetres of neutral 
glycerine, the two being stirred together with a glass rod till a thor- 
oughly homogeneous moist paste is produced. This is next diluted 
with 95 cubic centimetres of cold sterilized water, and shaken 
up till a perfect solution is produced; this solution is kept in a col- 
oured bottle in a dark place. As required, a 0.25-per-cent solution 
is made by mixing 2.5 cubic centimetres of the standardized solution 
with 97.5 cubic centimetres of sterilized water; a 0.50-per-cent solution 
by mixing 5 cubic centimetres with 95 cubic centimetres of water; a 
1-per-cent by mixing 10 cubic centimetres, and a 2-per-cent by mix- 
ing 20 cubic centimetres of the standardized solution with 90 and 80 
cubic centimetres, respectively, of sterilized water. A very good way 



INFECTIONS OF THE UTERUS 375 

to use the Colombeni solution is to saturate a ribbon of sterilized gauze 
with it and insinuate it into the uterus. The uterine packing at this 
time, whether of protargol, pure carbolic acid, or pure lysol, exercises 
a profound bactericidal influence, and does not carry the infection 
upward into the uterus, for the reason that any micro-organism that 
may come in contact with the saturated gauze will be destroyed. The 
gauze should be removed after forty-eight hours, and should be re- 
placed after an interval of another forty-eight hours. In cases of 
chronic gonorrheal infection of the uterus, the cocci have found 
hiding places in deep folds of the endometrium, whence the disease 
has been looked upon by some observers as self-limiting, while others 
with equal emphasis insist that it is more or less constantly revived. 
It is a matter of clinical observation that in these cases there occur 
periods of quiescence, followed by exacerbations that are not induced 
by fresh infections. 

Jadassohn (Correspondenz-blatt fur Schweizer Aerzte) asserts that 
chronic gonorrhoea in certain cases may become acute through super- 
infection with their own cocci. He reaches this conclusion notwith- 
standing the observation of Wertheim, that a mucous membrane 
affected with chronic gonorrhoea did not react to cultures taken 
directly from it, although it reacted to cultures taken from another 
patient. 

The mucous membrane does not become so used to the presence 
of the cocci that the latter can live as saprophytes on it after the 
tissue has become normal. On the contrary, the inflammation re- 
mains for a time after the infectious elements have disappeared. He 
concludes, also, that chronic gonorrhoea may become acute, not only 
through the increase of its own gonococci, but by reinoculation from 
another person. While there are instances in which the membrane 
does not react to inoculation with gonococci from any source what- 
ever, they are to be looked upon as exceptional, and the generally 
entertained theory, that the mucous membrane that has been the seat 
of a chronic gonorrhoea thereby acquires immunity, is to be abandoned. 
It is not proper, therefore, to look upon chronic gonorrhoea of the 
uterus as a self-limiting disease, but rather as one that is capable 
of indefinite perpetuation. Treatment should, therefore, be directed 
to the eradication of the infection, which, if left to itself, will, in 
at least 50 per cent of the cases, extend upward into the Fallopian 
tube. If this has not already taken place, and if there is no acute 
infection in the adnexa or other perimetric structure, curettage should 
be practised. (See Curettage.) The treatment should in no wise differ 
from that already prescribed for chronic infectious endometritis, with 
the exception that it is better to select some distinctly antigonorrhceal 
remedy, such as protargol, carbolic acid, or lysol, with which to 
pack the uterus after its cavity has been scraped. This is not a 
dangerous procedure when done skilfully and under proper antiseptic 
precautions, all alarmist declarations to the contrary notwithstanding. 



376 A TEXT-BOOK OF GYNECOLOGY 

Streptococcosis Infection. — Puerperal fever is the ordinary clinical 
manifestation of uterine infection by the Streptococcus pyogenes — other- 
wise known as the micrococcus of erysipelas, Streptococcus erysipelatos, 
Streptococcus longus, etc. (See Streptococcus Pyogenes.) 

As elsewhere stated, Oliver Wendell Holmes was the first to direct 
attention to the relationship of cause and effect between erysipelas 
and puerperal fever, an observation which was confirmed by Stille, 
who reported ninety-five cases of puerperal fever occurring in rapid 
succession in the practice of a single physician in Philadelphia, in 
which fifteen of the children died from erysipelas. Fehleisen was the 
first to demonstrate that the Streptococcus pyogenes was the essential 
micro-organism of erysipelas. That this same micro-organism is the 
materies morbi by which the parturient woman is infected with re- 
sulting puerperal fever is supported by cumulative evidence. Clivio 
and Monti demonstrated its presence in five cases of puerperal peri- 
tonitis; Widal found it in sixteen; Czerniewski found it in the lochia 
of thirty-five out of eighty-one women with puerperal fever. Bumm was 
able to find the streptococci alone in five cases (three of these end- 
ing fatally). In twelve cases, besides the streptococci, there were ob- 
served upon the plate cultures staphylococci and other germs. In 
eight cases the number of germs of decomposition were very great 
(mixed form of septic and putrid endometritis). Two of these cases- 
terminated fatally, the streptococci entering the venous thrombi at 
the placental site and a pyaemia resulting. 

Occasionally we may find pyogenic staphylococci, especially the 
aureus, besides the streptococci. Bumm only observed staphylococci 
alone in two cases. The cases were mild ones, and this coincides with 
the observations of Fehling. 

The pathology of infection by the Streptococcus pyogenes is typically 
manifested in the uterus. This micro-organism, introduced into the 
vagina by the finger of the accoucheur or upon instruments em- 
ployed in delivery, finds in the fluid contents of the uterus a congenial 
culture medium in which it propagates with great rapidity. The 
placental site serves as an enormous infection atrium, the wide, dis- 
tended lymphatics and the open blood vessels alike serving as portals 
for the reception of the poison, which is speedily transported thence 
to the general system. In the uterine structure, however, is mani- 
fested the characteristic action of the streptococci. As soon as they 
invade the vessels of the uterus they produce changes which break 
down the endothelium and result in the development of a thrombus. 
After a while, the thrombus in turn breaks down, and the emboli 
thus formed spread the organisms in various directions. Many of them 
lodge in the immediately adjacent vessels of the myometrium, while 
others, gaining access to the systemic circulations, sanguiferous and 
lymphatic, are conveyed to distant organs and structures, where they 
become foci of secondary suppuration. In the uterus itself, however, 
there are speedily established, either primarily or secondarily, similar 



INFECTIONS OF THE UTERUS 377 

foci of suppuration, by which the organ may become converted into 
what may be described as an aggregation of small abscesses. The 
individual accumulations of pus may vary from a few drops to a 
drachm, or even more. Occasionally two or more of these centres 
of suppuration may coalesce, forming a larger abscess cavity. It should 
be borne in mind that these suppurative changes occur in the myo- 
metrium, and that the condition is essentially one of interstitial sup- 
purative metritis. The invasion of the lymph spaces by the strepto- 
coccus results very speedily in the development of an acute septic 
lyniphangeitis, involving the lymphatics, first, of the pelvis, and, sub- 
sequently, of the remoter parts of the system. The lymphatic glands 
may, themselves, become foci of suppuration. It should be remem- 
bered, however, that the streptococci do not produce suppuration so 
promptly as do the staphylococci, and that, consequently, in the cases 
under consideration, pus does not appear in the uterine structures at 
once. In the earlier stages of the infection there occurs simply a 
diffuse infiltration of the tissues, which, if incised, will set free a 
clear yellowish fluid in which are a few pus cells. As the streptococci 
develop, however, they manifest their characteristic effect of pro- 
ducing a coagulation necrosis, which becomes the focus of suppura- 
tion. In the course of a few days, a parturient uterus which is 
the seat of this infection may vary in length from 15 to 18 centi- 
metres, and in fundal width from 12 to 15 centimetres. The uter- 
ine wall at the fundus is about 3 centimetres in thickness. When 
cut open, the interior of the uterus above the cervical canal is 
covered with a dark tenacious mucus, which is very offensive. The 
placental site is distinct, and may contain fragments of firmly attached 
placenta. The incised myometrium, as in Cartledge's cases (Trans- 
actions of the Southern Surgical and Gynecological Society), reveal 
numerous small discrete abscesses varying in size from a millet seed 
to a large pea. This description of the general maeroscopical appear- 
ance is based upon examination of the uterus removed by vaginal 
hysterectomy during the course of the disease, and does not, therefore, 
depend upon post-mortem changes for any of the peculiarities recorded. 
Bumm (Arrhir fiir Gynakologie) has made careful studies of the 
endometrium, when the seat of puerperal infection, and agrees with 
Vidal that this structure is the avenue of ingress for the pathogenic 
micro-organisms that cause the disease. From the endometrium they 
enter the system in two ways, viz.: first, through venous thrombi, which 
carries them directly into the circulation, and. secondly, through the 
lymph channels where they may either lodge in the lymphatic glands 
themselves or develop foci of suppuration in connective tissue. Kehrer 
classifies puerperal endometritis into putrid and septic. In putrid 
endometritis, he asserts that saprophytic micro-organisms cause a 
change in the decidua. in which septic germs do not develop. This 
change, he contends, affects only the uppermost layer of the decidua, 
which is exfoliated as the new mucous membrane forms beneath it. 



378 A TEXT-BOOK OF GYNECOLOGY 

These changes, he considers, are manifested by fever and other symp- 
toms of intoxication due to decomposition. Kehrer, however, admits 
that saprophytic infection is exceedingly rare, and that in the majority 
of cases of endometritis following abortions and labours, bacteriologi- 
cal examination reveals the presence of septic micro-organisms, espe- 
cially streptococci, and sometimes pyogenic staphylococci, so that, as 
already contended in this chapter, the cases are in reality examples of 
mixed infection. In the histological examination of a case of so- 
called putrid endometritis in which, notwithstanding the presence of 
streptococci, a predominating influence seemed to be exercised by the 
saprophytes, the following histologic conditions were observed: the 
superficial layer of the decidua was filled with micro-organisms, among 
which were all forms of rods, long threads, and cocci of all sizes. 
Fungi were found growing in colonies entirely covering the base of the 
decidua. The tissues were found in a state of necrosis, glassy and 
cloudy, at a point 0.1 millimetre beyond the area occupied by the fungi. 
The granules could not be stained. Beyond the zone of infection a 
zone of cellular infiltration had formed. Numerous small round cells 
were observed which looked like colourless blood corpuscles and formed 
a layer 0.3 to 0.5 millimetre thick; they were lying close together. 
The zone of cellular infiltration occupied a position between the super- 
ficial area of infection and the muscularis. The fibres of the myome- 
trium, however, were found occasionally to be separated in places by 
an accumulation of cells, but this condition did not penetrate deeply 
into the muscularis. The round-celled infiltration, according to Bumm, 
must be looked upon as an effort on the part of Nature to set up 
a granular wall to act as a barrier against the entrance of the germs, 
and thus to separate the dead from the healthy tissue. The fact, how- 
ever, that neither Bumm nor Kehrer have succeeded in demonstrating 
the existence of this so-called putrid endometritis, independently of 
the existence of streptococci in large, if not in preponderating num- 
bers, indicates that the effort to establish a variety of infection depend- 
ing upon the existence and the action of the saprophytes is not war- 
ranted by the facts. This becomes the more apparent when considera- 
tion is given to the histological appearances of what Kehrer and Bumm 
designate as septic endometritis. The mucous membrane in these 
cases is necrotic and reveals the remains of the spongy layer, thor- 
oughly covered with streptococci yielding pure cultures. The cocci 
occur in thin layers, while in other places they appear as large colonies 
occupying considerable areas. There is a reaction zone, less pro- 
nounced but none the less persisting, just as defined as in the putrid 
variety. The protection, however, thus afforded, seems to be less com- 
plete, as there are fewer round cells, and the necrotic zone disappears 
into the neighbouring tissues without showing any sharply defined 
boundary. In these situations the streptococci grow and penetrate 
deeply into and through the striae of the myometrium. The muscular 
tissue itself reveals an opacity in the presence of large accumulations 



INFECTIONS OF THE UTERUS 379 

of cocci. "Where these accumulations occur, they are surrounded by 
small collections of round cells; in some places the lymph spaces are 
filled with cocci, while, at the placental site, the venous spaces are 
closed and contain neither thrombi nor cocci. A few venous branches 
near the surface, however, contain blood clots which inclose a few of 
the cocci. An extension of the infection from the surface into the 
lymph spaces is demonstrable in numerous sections. Some of the finer 
lymph spaces show a delicate fungus border on their walls, while 
others are empty or filled with granular material. When the infection 
occurs within the lymph channel, it does not seem to provoke reaction 
in the surrounding structures. In other locations, the lymph spaces 
are filled with fungi, while the cocci are observed in the surrounding 
tissues. In still other places, the lymph channels are filled with cocci, 
whence the fungi spread beyond the necrotic muscular layer, pro- 
voking a reactionary accumulation of cells in the adjacent tissues. 
The inflammation, thus centring about different foci, may result in the 
liquefaction of the entire infected mass, changing it into an abscess 
cavity. Bunim raises the important question: How can we explain the 
fact that the affection sometimes remains local, while in other cases it 
invades the lymph channels or the veins? His answer is that the 
bacteria must explain this. They are beyond question the agents 
which produce this form of disease. The danger exists, not in their 
number, but in their virulence. In making this statement he simply 
emphasizes the observations of Yidal and Chantemesse. In the local 
septic infection, and in the thrombotic forms, the germs are only 
mildly virulent and are made harmless by the speedy reaction that 
occurs in the organism. On the other hand, the extremely virulent 
germs penetrate the walls of the uterus and there is no local reaction. 
The germs occurring in the lymphatic form he would place midway in 
virulence between the extremely virulent, or, as he expresses it, the 
internal, puerperal, erysipelatous form, and the mild, local or throm- 
botic forms. In view of these facts and of the practical identity in 
character, if not in degree, of the pathologic changes, and in view of 
the demonstrated common etiology, all of which is at least inferentially 
admitted by Bumm, there can hardly be said to exist any substantial 
reason for discriminating between the different varieties of infection 
as they are manifested in puerperal fever. On the other hand, the 
evidence seems to be cumulative that this infection should be recog- 
nised as depending for its essential characteristics upon the Strepto- 
coccus pyogenes, and that occasional modifications due to the presence, 
in vaiying proportion, of saprophytes and other micro-organisms, 
should be recognised as incidental rather than essential variations. 

It is important to remember that infection which may invade the 
lymph channels, may travel through those highways to the peritoneal 
surface, occasioning thereby a true infection of the peritoneum. It 
has been stated that in parenchymatous suppuration of the uterus the 
infection may penetrate directly through the tissues to the peritoneal 



380 ^ TEXT-BOOK OF GYNECOLOGY 

surface; but, be this as it may, the fact remains, that streptococcous 
infection of the interior of the uterus is speedily followed in many 
cases by involvement of the peritoneum. When infection of the peri- 
toneum takes place, the serous secretion, which is copiously thrown out, 
becomes a culture medium for the rapid reproduction of the strepto- 
cocci, which are rapidly absorbed thence by the numerous stomata of 
the peritoneum. Puerperal peritonitis is, therefore, always associated 
with profound systemic intoxication. Another avenue by which the 
infection may reach the peritoneum is that of the Fallopian tube, 
which is frequently invaded by the progressive contamination of con- 
tiguous mucous surfaces. As a rule, however, the moment that septic 
inflammation is established within the Fallopian tube, the distal, or 
fimbriated, extremity becomes sealed, thus converting the tube into 
a sort of retention cyst. Leakages may occur, however, particularly 
when the tubal distention has resulted in rupture. 

The symptoms of streptococcous infection of the uterus begin with 
a chill, which may or may not be preceded by fever. The temperature 
reaction, however, which follows the initial chill is generally severe. 
The lochia which, up to this time may have been normal in quan- 
tity, colour, odour, and consistence, are temporarily checked, become 
darker in colour, more viscid, and have an offensive odour. The ther- 
mic range now becomes characteristically irregular. Another chill, 
which may be either slight or severe, is followed by a profuse perspira- 
tion, generally of a clammy character, succeeded by marked exhaus- 
tion. The chills now become irregular, recurring either daily, or 
sometimes skipping a day; in which case two or three chills may 
occur in the course of 12 or 24 hours, being then followed by an- 
other interval of immunity. The chills are, however, more prone 
to occur during the evening or the night than in the morning or after- 
noon. The fever curve may show an evening exacerbation followed 
by a morning remission, as in certain forms of malarial toxaemia, but, 
as a rule, the vacillation is of a very lawless kind. As a rule, the first 
febrile manifestation amounts to three or four degrees; after this, there 
is a slight remission involving a drop of one or two degrees; then a 
slight rise and a slight fall. The rise rarely reaches the original eleva- 
tion and the fall never approximates the normal line. In the course of 
eight or nine days, however, it will be discovered that the vacillations 
are a little more pronounced — i. e., the elevations are a little higher 
and the depressions a little lower than formerly, while the vacillations 
occur with greater frequency than before. There seems to be a con- 
stant tendency for the highest and lowest points to get farther and 
farther apart. There are, of course, individual exceptions to the rule 
just given. In the presence of a particularly virulent infection the 
initial chill may be very profound, the elevation of temperature may 
be high and may so continue during the course of the disease, showing 
but very slight remissions. The cardiac centres are early influenced 
by the infection, the pulse rising to 120, or higher, and being generally 



INFECTIONS OF THE UTERUS 3S1 

soft and compressible. The respiration is rapid, the tongue speedily 
becomes coated, generally with a white fur, though ordinarily moist. 
There is not, as a rule, marked disturbance of digestion, particularly 
to the degree which occurs in septicaemia. As the disease advances, 
however, the patient becomes emaciated and anxious, and delirium 
may supervene, although in some cases the intelligence remains intact 
until a short time before death. 

The diagnosis of streptococcous infection of the uterus is made, 
first, by a careful estimation of the preceding symptoms; and, subse- 
quently, by detection of the streptococcus. A curette or a curette 
forceps may be passed into the uterus, when some of the debris of 
degeneration can be removed. Microscopic and bacterial examination 
of the scrapings will reveal the presence of the Streptococcus pyogenes 
but in association, perhaps, with other micro-organisms. It will, how- 
ever, be found in such preponderating numbers that the essential 
character of the infection can not be mistaken. A drop of blood taken 
from the tip of the finger or from the ear will reveal the presence of 
the streptococcus and blood plaques in the presence of a pronounced 
leucoeytosis. The red corpuscles are diminished in number, many of 
them presenting a shrunken appearance. 

The treatment of streptococcous infection of the uterus must have 
a threefold object, namely, (1) to arrest the infection, if possible, at 
its point of entrance; (2) to eliminate the poison from the system after 
the invasion has passed beyond the point of entrance; and, (3) to 
support the patient during the course of the pyaemic sequelae of the 
infection. 

A moment's consideration of the pathology of this infection renders 
it unnecessary to emphasize the importance of prompt intervention to 
arrest the infection. The first signs of temperature disturbance, 
whether an initial chill followed by fever, or an initial pyrexia with- 
out a chill, associated with a change in the quantity, colour, and 
odour, of the lochia, should be the signal for a careful exploration of 
the uterus. If, from examination, the fact is determined that the 
symptoms are of intrauterine origin, there should be no hesitancy in 
practising thorough curettement under the most rigorous antiseptic 
precautions. With reference to the use of the curette under these 
circumstances much unnecessary dispute has arisen. Those who ques- 
tion the expediency of its employment apparently fail to take into 
account, either the character of the infection, or the primary patho- 
logic changes which it induces. The formation of thrombi in the 
orifices of the veins in the placental site is, of itself, sufficient to 
materially diminish the outflow of fluid from that source; while the 
inflammatory exudation arrests the free escape of serous elements from 
the intervenous areas. At this juncture. Nature is found in the act of 
rallying her resources to repel the invader, and there may be said 
to be a temporary check in the course of the infection. This is pre- 
cisely the time when treatment, to be of the most value, should be 



382 A TEXT-BOOK OF GYNECOLOGY 

applied with the most thoroughness. The patient should be anaesthe- 
tized; placed upon the table in the recumbent position; a Jones's, or 
other perineal retractor should be used; the vagina should be thor- 
oughly irrigated; and the uterus should be washed out by means of a 
recurrent catheter. A sharp curette with a blunt, protecting edge, like 
that of Gau's, should be inserted, and the uterine wall should be thor- 
oughly scraped. If free bleeding is induced, so much the better, as the 
hemorrhagic current has the mechanical value of washing away remain- 
ing elements of infection. Great care should be taken to avoid pene- 
tration of the soft uterine wall. After the interior of the uterus has 
been thoroughly curetted, the cavity should be washed out by a 1-to- 
2,000 solution of the mercuric bichloride, a recurrent uterine irrigator 
being employed for the purpose. The uterine cavity should then be 
packed with a long ribbon of iodoform gauze saturated with sterilized 
glycerine. Glycerine, by virtue of its hygroscopic qualities, favours 
an outward current of transudation, and thus, if it does not promote 
elimination of any remaining infection, it, at least, offers some barrier 
to the further invasion of the tissues. The patient should be placed 
in the recumbent posture at the expiration of twenty-four hours, when 
the uterine packing should be removed and carefully reapplied after 
the uterine cavity has been again irrigated by the sublimate solution. 
There is no occasion to repeat the curettement provided that it has 
been well done, and the patient will not, therefore, require an anaes- 
thetic. The dressing should be changed at similar intervals during 
three or four days, when, if the temperature range becomes normal, 
the treatment may be discontinued. Some excellent practitioners 
employ constant irrigation of the uterine cavity, instead of packing 
with iodoform or other antiseptic agents, and very good results have 
been reported from this course of treatment. For its accomplishment 
a reflux uterine irrigator, such as that devised by Gaither, should be 
used. This is an excellent instrument, and secures the reflux current 
by effecting the dilatation of the cervix to any desired degree. It is 
more valuable than the ordinary tubular instruments, which are prone 
to become choked by clots or other debris. 

The object of curettage is only half realized when the infected 
debris has been scraped away; it is equally imperative to asepticize, so 
far as possible, the remaining endometrium. To accomplish this, the 
uterus may be packed as indicated in the preceding paragraph. Some 
excellent practitioners employ constant drainage with the best results. 
Ill {Transactions of the American Association of Obstetricians and 
Gynecologists) packs the uterus with iodoform gauze, which is kept 
saturated with an antiseptic medicament applied through a hollow 
curved tube (Fig. 155). This ingenious arrangement secures both an 
influx and an efflux of fluid, and is deserving of consideration. 

If, however, in spite of these precautions the temperature con- 
tinues to vacillate and to show a characteristic pyaemic range, and 
particularly if the pulse goes to 120, with a tendency to increase 



INFECTIONS OF THE UTERUS 



383 



in frequency and to diminish in force and volume, the evidence is 
to be construed as meaning that the infection has invaded the lymph 
channels, and that the myometrium has become the seat of diffuse in- 
fection, if not of multiple suppurations. It is manifest that, under 
these circumstances, the disease has passed beyond the control of such 
a conservative measure as curettement. The condition indicated by 
this persistence of symptoms is one which, if left alone, is calculated 
constantly and progressively to re-enforce the systemic infection, and 




Fig. 155. — ■" 111 packs the uterus with iodoform gauze, which is kept saturated with an anti- 
septic medicament applied through a hollow curved tube." — Eeed (page 382). 



thereby to keep alive a pysemic state which must result in death. An 
intelligent comprehension of the symptoms and of the underlying 
pathologic conditions can not result in any other conviction than that 
the line of treatment must be complete removal of the uterus. Success- 
ful cases of this character have been reported by Yineberg, Cartledge, 
and others. The operation may be done either through the vagina 
or by abdominal section. The latter route is generally preferable, 
for the reason that the uterus may be too large to be easily de- 
livered through the vagina, while in its septic state, its morcella- 



384 A TEXT-BOOK OF GYNECOLOGY 

tion would be a dangerous expedient. Extraordinary antiseptic pre- 
cautions should be taken in making an abdominal section under these 
circumstances. The patient should be prepared by a thorough vaginal 
and intrauterine irrigation, and the uterus should be packed with dry 
iodoform gauze. It may not be amiss to close the os externum by 
passing a single suture through the anterior and posterior lips of the 
cervix. By this means the field of operation will be fairly well pro- 
tected from contamination. These preliminary steps should be taken 
by the assistant, or, if by the operator himself, he should employ 
rubber gloves for the purpose. As soon as the intravaginal manipu- 
lations are concluded the rubber gloves employed at that time should 
be taken off, and should be replaced by another pair carefully steril- 
ized. In this way, alone, can the operator feel sure of giving reason- 
able protection to his patient. The operation should be that of pan- 
hysterectomy, involving, as the name implies, the removal of the 
entire uterus with its appendages. The technique of the operation 
does not differ in any particular from that described in the chapter 
on panhysterectomy. It is well, as a matter of routine, to practice 
hypodermoclysis both before and after the operation, three or four 
pints of water being administered in this way. 

Supporting treatment should be adopted from the start, care 
being taken to preserve the digestive functions, which, happily, are 
not, as a rule, seriously compromised in these cases. Stress has been 
laid upon alcohol as an article of diet, and the testimony seems to 
support the claims for its consideration. Whisky may be given in 
the form of milk punch every few hours. Wines are not, as a rule, 
so well borne, and beer is more prone to disturb the gastric and 
other functions. Mild acidulous drinks are usually demanded, to con- 
trol the generally persistent thirst. The bowels should be kept relaxed, 
but active purgation should be avoided. The old theory of treating 
these cases with cathartics to favour the elimination of the poison, 
is, in the light of the now well-understood pathology, a fallacious 
doctrine. 

The suggestion has been made that in view of the probable up- 
ward extension of the infection in puerperal fever, and of the con- 
sequent involvement of the Fallopian tubes, a sound should be passed 
through the uterine cavity and the orifice of the tube for the pur- 
pose of drainage; some, indeed, have gone so far as to suggest the 
expediency of irrigating the Fallopian tubes. (See Infections of the 
Fallopian Tubes.)' A method of this kind is unsurgical in the extreme, 
for the reasons, first, that no surgeon, however deft he may be, can 
be sure of the distention of the tube; and, next, that he can not dis- 
tinguish the orifice of the tube within the uterine cavity in the post- 
parturient condition. The most that he will be likely to accomplish by 
the procedure is to establish a fresh infection atrium within the uterus. 

Tuberculosis of the Uterus. — A description of tuberculosis of the 
uterus must be divided into two parts, since it is a well-established fact, 



INFECTIONS OF THE UTERUS 385 

according to Whitacre, that tuberculosis of the body of the uterus and 
tuberculosis of the cervix are quite independent of each other. A lesion 
beginning in one portion rarely passes beyond the anatomic dividing 
line (the internal os), and the pathologic changes which the tubercle 
bacillus causes are markedly different in the two regions. 

Tuberculosis of the Cervix Uteri. — Tuberculosis of the cervix is a 
condition which was declared by Kokitansky and Lebert not to exist, 
and Spaeth in 1885 collected only six cases. Since 1886, however, 
when Hegar demonstrated the clinical importance of genital tuber- 
culosis, and since the introduction of routine methods of bacterial and 
microscopic examination of cervical secretions and curettings, the num- 
ber of cases has multiplied rapidly, and tuberculosis of the cervix is 
looked upon at the present day as a condition that must enter into the 
diagnosis of every lesion of the cervix. 

The disease is usually secondary to tuberculosis of the Fallopian 
tubes, peritoneum, or vagina, yet it may be the sole seat of tuberculosis 
in the genital tract of phthisical women, or, as in the cases of Fried- 
lander and Pean, it may represent the only seat of tuberculosis in the 
entire body. The relative infrequency of cervical tuberculosis has 
been explained by the resisting power of the squamous epithelium on 
the portio vaginalis, and by a natural antibacterial action of the cervi- 
cal canal, as has been demonstrated experimentally by Menge. Pre- 
disposing causes of infection are undoubtedly to be found in irritating 
discharges, lacerations, and erosions. It is difficult to explain the 
immunity of the uterus to a simultaneous infection when the lesion is 
clearly secondary to a tuberculosis of the Fallopian tubes or perito- 
neum. The monthly exfoliation of the corporeal endometrium prob- 
ably plays a definite role (Sippel, Vassmer, Schottlander). The infec- 
tion of the cervix may take place by an extension from either the 
higher or the lower parts of the genital tract, by way of the blood 
stream, or by direct inoculation from without. 

Moroid Anatomy. — In describing the lesions of tuberculosis of the 
cervix Whitacre recognises: 

1. A miliary form. 

2. A diffuse tuberculous infiltration with ulceration. 

3. A papillary form. 

Schiitt describes a fourth form in which the lesion consists of an 
apparently simple bacillary catarrh, which is limited to the epithelium 
and forms a caseous layer over its surface. Daurios has suggested a 
fistulous form, but the occurrence of fistula? must be considered acci- 
dental. 

The miliary form may be looked upon as the first stage of the 
diffuse tuberculous form, and may be described as a catarrhal inflam- 
mation of the cervical mucosa with the presence beneath the epithelial 
surface, of miliary tubercles too small to be seen by the naked eye. The 
folds of the arbor vita? become enlarged and produce pronounced villosi- 
ties and secondary villosities with deep fissures between the folds. The 
26 



386 



A TEXT-BOOK OF GYNECOLOGY 



epithelium over the surface remains intact, and small masses of round 
cells containing giant cells, and a few tubercle bacilli, are found in 
the stroma which is at the same time the seat of a small round-celled 
infiltration. The glands are not at first involved. Below the mucous 
membrane, miliary tubercles of larger size are found, and even when we 
have to do with a tuberculous eruption which is slight, superficial, of 
recent date, and has caused no destruction of tissue, we must expect to 
find the muscular layers infiltrated by miliary tubercles which are 
formed along the course of the blood vessels. The condition may con- 
tinue as a miliary tuberculosis, the most frequent form of cervical in- 
volvement, or the miliary tubercles may increase in size and number, 
become caseous, and run together to form the lesions of the second or 
diffuse form, where the mucous membrane is converted in part, or in 
its entirety, into an ulcerating caseous mass. When this occurs, the 
glandular elements show every degree of destruction, the tissues show 
infiltration and thickening, and the cervical canal becomes a worm- 
eaten cavity containing caseous material (Matthews). The interior of 
such a cavity is lined by tuberculous granulations which bleed easily 
and exude a heavy discharge, and the muscular tissues are infiltrated 
by discrete miliary tubercles. There is a marked tendency to fibrous 
infiltration, as was first pointed out by Williams. 

The papillary form of cervical tuberculosis, as reported by Frankel, 
Cornil-Pean, Franque, and Yitrac, possesses a special interest from a 

clinical point of view 
because of its naked- 
eye resemblance to 
carcinoma (Fig. 156). 
It is characterized by 
a papillary growth of 
the arbor vitse which 
pushes back the pave- 
ment epithelium of 
the portio vaginalis 
and attains a consid- 
erable tumour forma- 
tion. These tumours 
show slight tendency to break down and present the typical microscopic 
picture of tuberculosis. Their naked-eye appearance is not typically 
tuberculous. 

Symptoms and Diagnosis. — In determining the symptoms of tuber- 
culosis of the cervix it is difficult to separate them from the symptoms 
of the primary disease, which is often of much greater importance than 
the lesion in the cervix. A primary cervical lesion gives no pain, and 
there is usually present a muco-purulent leucorrhcea which may be 
occasionally tinged with blood. A physical examination of the cervix 
will reveal one of the conditions previously described. 

The diagnosis of tuberculosis from simple cervical endometritis on 




Fig. 156. — "The papillary form of cervical tuberculosis.' 
"Whitacre. 



INFECTIONS OF THE UTERUS 



387 



the one hand and carcinoma on the other forms an important feature 
in the description of tuberculosis of the cervix. 

The condition will be distinguished from simple cervical catarrh 
by the amount of destruction taking place in the tuberculous ulceration, 
by the presence of caseous material in the discharge, and by the demon- 
stration of the tubercle bacillus in the cervical secretions. Some con- 
fusion with chancroid has arisen in cases reported by Spaeth and Zwei- 
f el. In the ulcerative and papillary form of the disease, the possibility 
of confusion with the much more common condition of carcinoma must 
be constantly borne in mind. Many cases of tuberculous cervicitis 
have been operated on for carcinoma and their true nature only re- 
vealed on microscopic examination (Cornil, Frankel, Kaufmann, Gog- 
lio, Vitrac, Emanuel) ; and it is probable that many such mistakes pass 
unrecognised when the material is not submitted to microscopic ex- 
amination. The following table has been arranged by Whitacre to aid 
the diagnosis between the two conditions: 





Tuberculosis. 


Epithelioma. 


Size 


Small. 

Papillary form : A muriform 
mass with small vegetations in 
the vicinity. Ulcerative form : 
Surface covered by caseous 
material and mucus. Border 
a seed bed of granulations. 

Papillary : Rose- red, deeper col- 
our than surrounding. Ul- 
cerative: Bottom yellowor red. 

Papillary : Surface knobbed, 
smooth, polished, elastic, no 
induration, limits not clear. 
Ulcerative : Depression with- 
out diffuse induration. Bor- 
der granular. 

Little or none 


No regularity. 

Usually fungous. The 
cavity form lacks gran- 
ulations in the edges. 
Never solely intersti- 
tial. 

Grayish. 

Surface roughened, con- 
sistence very hard. If 
large and fungous, the 
base is very hard. 

Characteristic. 


Aspect 


Colour 


Touch 


Spontaneous pain 

Sensitiveness. . 


Present 


Absent. 


Bleeding 


May be slight in both papillary 
and ulcerative form. 

Papillary : Mucous. Ulcera- 
tive : Often purulent. 

Papillary: Extremely slow. Ul- 
cerative : Slow, yet may pro- 
duce extensive ulceration and 
fistula?. 

Both show typical miliary tuber- 
cles and tubercle tissue. 

Tubercle bacilli found in smear 
preparations, or by inoculat- 
ing guinea pig. 


Frequent and abundant. 
Foetid and abundant. 


Discharge 


Progress 


Progressive and accom- 
panied by constitu- 
tional symptoms. 

Typical epithelioma with 
pearls and columns of 
cells. 

None. 


Pathologic histology. . . 
Bacteria 







The treatment of tuberculous disease of the cervix should be radical 
when the disease is primary and whenever it will prolong the life or 
contribute to the comfort of the patient, but there are naturally many 
cases associated with advanced tuberculosis of the lungs, intestines, 



388 A TEXT-BOOK OF GYNECOLOGY 

or tubes, in which no operative measures would be justifiable. Any 
operation undertaken for the cure of the condition must be extensive, 
since Cornil and others have shown that, even in recently developed 
and apparently superficial tuberculosis, there is already an extension 
of miliary tubercles along the blood vessels into the deepest muscle 
layers. If the uterus can be demonstrated to be free a high amputa- 
tion of the cervix should be done, yet many authors insist upon hys- 
terectomy as the rational treatment because of the almost uniform 
involvement of the tubes, the difficulty of getting beyond the tuber- 
culous process, and the fact that there is no certain method of deter- 
mining the presence of a tuberculous endosalpingitis. (For technique 
see Panhysterectomy and Vaginal Hysterectomy.) Aron and Tillaud 
warn against forcible, mechanical handling of the cervix, since we may 
thereby set up a general tuberculosis. Palliative measures will consist 
in the thorough curetting and cauterizing of ulcers, the excision of 
fistula?, the treatment by iodoform, and cleansing douches. 

Corporeal Tuberculosis of the Uterus (Tuberculous Endometritis). — 
Tuberculosis of the body of the uterus, or tuberculous endometritis, 
must be described, as has already been stated, as a lesion distinct from 
tuberculous cervicitis, and its frequency, compared with that of the 
latter condition, will make it a much more important lesion. Tubercu- 
losis of the uterus occurs in two thirds of all cases of general tubercu- 
losis; it occurs in connection with tuberculous disease of other genital 
organs, or the process may be primary in the endometrium. From the 
point of frequency, the corporeal endometrium stands second among 
the female genital organs. This type, like all other forms of genital 
tuberculosis, has been studied more especially since Hegar called atten- 
tion to its clinical importance, yet the frequency of the uterine 
disease , has only been fully appreciated in the last few years since 
routine histological and bacteriological examinations of all curettings 
have been made. Its real frequency is certainly well shown by a series 
of six cases which were observed by Vassmer in the very short period 
of ten months. 

The uterus certainly may be infected by the tubercle bacillus either 
from above or from below, and its frequent association with tubal dis- 
ease would indicate that a descending infection is the more common. 
Coitus certainly must be considered to be a source of infection when 
we remember the frequency of tuberculous disease of the male genito- 
urinary tract, and particularly since the demonstration by Jani of 
tubercle bacilli in the semen and in the apparently healthy prostate 
and testicles of men suffering from phthisis. Numerous cases are 
reported where women suffering from genital tuberculosis have lived 
with tuberculous men. Jani has injected the apparently healthy tes- 
ticle of tuberculous men into the peritoneal cavity of guinea pigs and 
has produced a typical tuberculous peritonitis. It has been asserted 
that a tuberculous process arising from coitus is primarily a tubal 
tuberculosis, and that the uterus is secondarily infected. Instruments 



INFECTIONS OF THE UTERUS 389 

or the examining finger may carry infection, or the transfer niay he 
by direct self-infection from a tuberculosis of the vulva, vagina, or from 
tuberculous stools. The relative immunity of the vulva, vagina, and 
cervix, has been explained by their protecting flat epithelium, and in 
the uterine cavity we find again a decided protection in the monthly 
exfoliation of the mucous membrane. The puerperal state certainly 
predisposes to infection, as is shown by the authentic cases of Frorieps, 
Eokitansky, Heimbs, Brues, Geil, Schiill, and by the demonstration of 
tubercle bacilli by Hiinermann in a septic thrombus after abortion. 
Schmorl, Eockel, Thorn, and others, have reported cases of pregnancy 
that began and went to full term in spite of a caseous endometritis. 

The age of the patient seems to make little difference, yet Kauf- 
mann holds that the female organs show a predisposition to tuberculo- 
sis with the decline of their activity. 

Morbid Anatomy. — Pathologically, tuberculosis of the uterus is 
divided by most authors into — 

1. A miliary form without ulceration. 

2. A chronic diffuse or caseous endometritis. 

3. A chronic fibroid type. 

The second is the clinical type with which we are familiar; the first 
is the very earliest stage of the chronic diffuse form or a part of a gen- 
eral eruption of tubercles and gives no symptoms; while the third has 
been very rarely recognised. 

The study of these lesions will be much simplified by considering 
them to be different stages of the same condition, and by stating that 
conditions of number and virulence of the bacteria, mixed infection, 
and the activity of the reparative process, will determine the miliary, 
caseous, pyometric, or fibroid form. 

The miliary form begins by a deposit of minute tubercles in the 
interglandular substance of the mucous membrane of the fundus of 
the uterus near the entrance of the Fallopian tubes (Kelly, Cullen, 
Williams. TTalther, Vassmer). The epithelial surface remains intact, 
as does also the glandular element, and the presence of a few tubercles 
made up of epithelial cells alone, or of single giant cells containing 
tubercle bacilli, may be the only evidence of tuberculosis in the entire 
mucosa. Later, the epithelioid nodules are surrounded by small round 
cells, and still later giant cells appear in their centre and only remnants 
of the glands remain (Fig. 157). In more advanced cases, the miliary 
tubercles are more numerous, and the glandular tissue is so much affected 
that Cornil and Franque have characterized it as a chronic tuberculous 
endometritis with the principal participation of the glands, which be- 
come enlarged and show indistinct markings. Coincident with the 
glandular hypertrophy there is a strong infiltration of the interglandu- 
lar tissue (Abel). Polyp formation, however, which is so frequent in 
other types of endometritis, and which forms a distinct class in tubercu- 
lous cervicitis, does not occur, and nodules larger than a pea are never 
seen. Madlener and Zahn have reported cases in which large polypi 



390 



A TEXT-BOOK OF GYNECOLOGY 




were found to contain miliary tubercles and tubercle bacilli, but they 
are considered to be a secondary infection of a pre-existing polyp. 

The miliary tubercles finally run together, caseate, and break down 
to form irregular undermined ulcers, which, by their confluence, con- 
vert the endometrium into a caseous mass involving, first, the superficial 

layers, then, the entire 
^^^g§BB^^^^ thickness of the mucous 

membrane. Below this 
is a zone of typical tu- 
berculous tissue consist- 
ing of epithelioid cells, 
tubercles, giant cells, and 
a varying amount of 
gland remnants. It is 
important to remember 
that the caseous mass 
simply replaces the mu- 
cosa (Pozzi). The mus- 
cle tissue shows distinct 
miliary and submiliary 
tubercles which are 
formed along the course 
of the infiltrated blood 
vessels (Hofbauer). The 
muscle tissue is usually 
distinctly hypertrophied 
and finally becomes extensively infiltrated and destroyed. A mixed 
infection by the pyogenic cocci, when associated with mechan- 
ical obstruction of the internal os, will lead to pyometra — a very com- 
mon condition. 

The chronic fibroid type of tuberculous endometritis was first de- 
scribed by Williams as a miliary tuberculosis characterized by an ex- 
cessive development of fibrous tissue within and around the miliary 
tubercles. Thus far, it has been recognised on the autopsy table 
alone. 

The symptoms of the disease are not characteristic and are prac- 
tically those of an ordinary endometritis with thickening of the uterine 
wall. Pain, temperature, and a general tuberculous appearance are 
absent. There may be a noncharacteristic, mucopurulent, even case- 
ous, discharge, but Vassmer has found no discharge in a series of six 
cases. Amenorrhoea was present in the majority of reported cases, 
excessive bleeding very seldom; but menstrual disturbance is prob- 
ably not important. Suspicious points in the history will be the 
chronicity, the presence of a general tuberculosis, and tuberculosis in 
the husband. 

Diagnosis. — As has just been stated, the symptoms of tuberculous 
endometritis are not sufficiently characteristic to distinguish it from 



Fig. 157. — " Giant cells (b) appear . . . and only remnants 
of the glands (a) remain." — Whitacke (page 389). 



INFECTIONS OF THE UTERUS 391 

simple endometritis or carcinoma, and experience has shown that the 
diagnosis can only be made by detecting the tubercle bacillus in the 
histologic structure of tubercle tissue in scrapings from such a uterus. 
The tubercle bacillus has been found with varying frequency both in 
the secretions from the uterus and in uterine curettings (Walther, Veit, 
Peraire). In the beginning stages of the disease, their scarcity renders 
a diagnosis by this means extremely difficult, but in the more ad- 
vanced forms the bacilli are numerous. When not found by micro- 
scopic examination in curettings, their presence may be demonstrated 
by injecting the curettings into the peritoneal cavity of the guinea 
pig. A typical peritoneal tuberculosis will develop in from twelve days 
to four weeks if the bacilli are present, even in small numbers. 

The histological diagnosis is made difficult by the fact that the 
tubercles are not always typical, that a simple infiltration of the stroma 
looks much like tubercle tissue, and that giant cells are sometimes 
found in an interstitial endometritis. The presence of the epithelioid 
cells of tuberculosis in the stroma of the mucous membrane, together 
with the occasional distortion of the glands, may lead to a confusion 
with carcinoma. 

Treatment. — The question of the appropriate operative treatment 
for tuberculous endometritis is as yet sub judice. Certain operators 
would insist upon hysterectomy as soon as the diagnosis is made 
{Schauta, Pozzi, Fehling); while others would recommend simple 
curetting and subsequent cauterization with pure carbolic, and treat- 
ment by iodoform. Sippel, Walther, Meyer and Halbertsma report 
cases of complete cure after curetting, the latter after five years. Sip- 
pel has shown the healing influence of continued menstruation on dis- 
ease processes in the mucosa — a fact which must not be disregarded. 

It must be remembered, however, that tuberculosis of the uterus is 
generally secondary to tubal tuberculosis, and in the presence of 
advanced disease demanding removal of these organs there could be 
slight reason for preserving the uterus. The association of a unilateral 
tubal tuberculosis will call for a laparotomy for the removal of the 
tube, and a thorough curettement of the uterus. It must be remem- 
bered in removing tuberculous appendages, that a tuberculous endome- 
tritis probably already exists, and that the uterus should be curetted 
if left behind. Kelly has found a tuberculous involvement in such 
cases when it was entirely unsuspected. It is well to remember that 
these cases should not be considered malignant, and that conservative 
measures are indicated in selected cases. 

Syphilis of the uterus was formerly supposed to be of relatively 
frequent occurrence. This was due to the fact that, before the days 
of Emmet, the granular surface of a cervical ectropion was frequently 
mistaken for a true ulcer — often syphilitic in character. Since lacera- 
tion of the cervix has become a recognised condition, it is discovered 
that what was formerly looked upon as ulceration, is, as already 
stated, nothing more or less than the everted mucous membrane, 



392 A TEXT-BOOK OF GYNECOLOGY 

studded with hypertrophied follicles. Syphilis may occur as either a 
primary or a secondary affection of the uterus. 

Chancre of the cervix was recognised in 1838 hy Ricord, who found 
it in 12 out of 199 cases, or, practically in 6 per cent of women 
presenting themselves at his clinic with primary syphilitic sores. 
Schwartz found it in 93 out of 686 collated cases. Chancre of the 
cervix is of about the same frequency of occurrence as primary chancre 
of the vagina. This statement is based upon tables compiled by 
Grluck {Wiener medicinische Br esse, 1881), by which it appears that 
primary infection of the vagina occurs in from 0.87 per cent to + 6 
per cent of all cases of primary syphilis in women. Chancre of the 
cervix is generally single, although it may be multiple. It may 
coexist with chancre in some other part of the genitalia. Fournier 
(Annates de gynecologic, 1876) reported a case in which three chancres 
of the cervix coexisted with one involving the fourchette. Whitehead 
(Abortion and Sterility) reported a case of syphilitic ulcer of the cer- 
vix, associated with constitutional symptoms, while a similar case was 
recorded as long ago as 1859 (British Medical Journal) by Parker. 
Herman (Obstetrical Transactions, London, 1885) recorded a case of 
large chancre of the cervix, associated with distinct secondary symp- 
toms. Mackenzie (British Medical Journal, 1854) called attention to 
the fact that important pathologic changes in the uterus occur as 
the secondary results of syphilis. Parker confirmed this view. 

The symptoms of primary infection of the uterus consist of an 
ichorous discharge, associated with more or less general pelvic discom- 
fort. This circumstance generally leads to an examination when an 
ulcer not self-inoculable and presenting the characteristic physical 
features of a chancre, is revealed. These ulcers may vary in size from 
a minute disk to the size of a shilling. In Herman's case the ulcer 
was of the latter size and presented the appearance of a grayish- 
yellow slough, surrounded by an inflamed areola. The edges were 
sharp, discrete, and indurated. If of long standing, it may be asso- 
ciated with syphilides of the vaginal mucosa and the pudendal integu- 
ment. 

In chancre of the cervix the inguinal lymphatics are not involved, 
unless the condition coexists with a primary sore of the external 
genitalia. Intrapelvic lymphangeitis and lymphadenitis are, however, 
frequent concomitants. The lymphatic vessels can be felt like tender 
and tense cords above either fornix of the vagina; while the enlarged 
glands may be felt as distinct nodules in the superimposed cellular 
structure. Infection of the intrapelvic lymphatics may result in sup- 
puration of the glands — a condition which may, with propriety, be 
designated as an internal bubo. 

Secondary syphilis of the uterus is generally associated with a puru- 
lent discharge and with enlargement and tenderness of the portio 
vaginalis. Patches of redness, sometimes of a very dark colour, are 
frequently noticed on the cervix. In the centre of certain of these 



INFECTIONS OF THE UTERUS 393 

reddened areas, ulcerative tendencies are occasionally manifested. Care- 
ful examination will generally reveal slight deposits of cicatricial tissue 
on the cervix. Ulcers varying in size and appearance are occasionally 
found. 

Endometritis is a common accompaniment of these changes. It is 
to this condition that the tendency of syphilitic women to miscarry, 
is attributed. 

Careful bimanual exploration will generally reveal more or less 
hypertrophy of the entire uterus. Parker considers these symptoms 
indicative of syphilis, because, according to his observation, they are 
found in about 60 per cent of the cases of confirmed lues; while they 
are not found with anything like equal frequency in women in whom 
a syphilitic history can not be otherwise established. 

The diagnosis of chancre of the uterus can generally be made by 
careful study of the physical conditions presented. The promptness 
with which the lesion yields to antisyphilitic treatment, will dispel 
any remaining doubts as to the character of the trouble. Secondary 
syphilis of the uterus, however, may readily be confused with h} T per- 
plasia due to other infectious causes. 

A careful study must, therefore, be made, not only of the previous 
clinical history, but of the bacteriological features of the case. 

Treatment. — The treatment of these cases may be summarized as 
antisyphilitic. Chancre of the cervix should be cauterized, with 
either nitric acid, or the pure nitrate of silver. After the slough 
separates, the ulcer should be treated with iodoform, the vagina being 
kept packed with iodoform gauze. The parts should be carefully irri- 
gated, between dressings, with a l-to-2,000 solution of bichloride of 
mercury. Constitutional treatment should consist of the administra- 
tion of mercury, either in combination or alternating with the iodides. 
The more profound organic changes of the uterus may require atten- 
tion. Forcible dilatation of the cervix and vigorous curettage of the 
endometrium are the only means by which hypertrophy of the latter 
structure may be overcome. 

Echinococcous infection of the uterus, while not of common oc- 
currence, probably exists with greater frequency than is indicated by 
the records. The demonstration of hooklets in many so-called 
" hydatid moles " of the uterus is an indication of parasitic origin 
of, at least, an important number of these cases. It would seem as 
if a more careful investigation of these intrauterine products would 
tend to eliminate pregnancy as an essential element in their produc- 
tion, and to restrict their etiology within the category of infections. 
That echinococci may, however, attack the decidual structures of a 
recent pregnancy, is beyond doubt. These organisms may also invade 
the muscularis of the uterus. When the parenchyma is the primary 
locus of infection, the resulting parent cyst may develop, as does a 
myoma, either beneath the mucous membrane, or beneath the perito- 
neum. One of the earliest cases on record — i. e., MacXeven's {New York 



394 A TEXT-BOOK OF GYNECOLOGY 

Journal of Medicine, 1849) — was an example of submucous develop- 
ment, while a more recent case by Altormyan {Lancet, April 4, 1891) is a 
distinct example of subperitoneal development of the cyst. The same 
may be said of the case reported by Freund and Chadwick {American 
Journal of Obstetrics, 18 74-' 7 5). 

The symptoms of echinococcous infection of the uterus are not 
essentially pathognomonic. There is tumefaction in the uterine region; 
a sense of weight, that may run through several months or years; ces- 
sation or irregularity of menstruation; increasing pressure on the 
bladder and bowels; while there usually occurs a progressive decline 
of general health. The tumefaction, which is ordinarily median at 
its commencement, may develop either to one side or the other, accord- 
ing as the tumour grows either to the right or to the left. The 
tumour, itself, in a case of parenchymatous infection, is generally 
described as smooth and elastic. When it presents in the uterine 
cavity or at the cervical margin, it is generally fluctuating at the 
presenting point, although the palpation wave is transmitted but in- 
distinctly to remoter parts of the growth. In the uterine cavity, the 
cyst may present many features in common with the amniotic sac for 
which it has been mistaken. In cases of echinococcous infection of the 
uterine cavity, the symptoms may be essentially those of pregnancy. 
The uterus becomes enlarged and softened, the cervix presenting a 
bluish aspect. The womb enlarges, progressively and symmetrically, 
the breasts enlarge and may contain milk, while there are not infre- 
quent reflex disturbances of the stomach. It is the occurrence of these 
symptoms which has generally caused infections of the uterine cavity 
by the echinococcus, to be looked upon as pregnancy, and the result- 
ing cysts to be designated as degenerated ova. In practically all 
these cases, however, the usual amenorrhcea of pregnancy is absent, 
while the patient complains of more or less constant dribbling of blood 
from the uterus. While this is true, the fact must be recognised that 
infection of the uterine cavity by the echinococcus may coexist with 
pregnancy, as was true in MacNeven's case, in which a large echino- 
coccus cyst was expelled, intact, during a true labour and immediately 
preceding the rupture of the amniotic sac. The exact diagnosis can 
not be made without the demonstration of the hooklets. Echinococcous 
infection of the uterus may occur at any age. Szancer {Z eitsclirift fur 
Geburtshulfe una 1 Gynakologie, 1879) reports a case occurring in a 
girl of twelve, while Hislop reports one aged seventeen, and it has 
been found in patients of more advanced years. 

Invasion of the uterus seems to be effected through any abrasion 
in the mucous surface, although, in a number of cases, the infection 
of the uterus has been secondary to the invasion of remoter organs, 
notably the liver. Microscopically, the cysts consist of structureless 
stratified membranes, containing scoleces and separate echinococcic 
hooklets. The cysts, themselves, multiply by endogenous prolifera- 
tion, the resulting mass consisting of a large mother cyst containing 



INFECTIONS OF THE UTERUS 395 

numerous daughter cysts, varying in size from a millet seed to a pea, 
or even larger. Each cyst contains clear, limpid fluid, containing 
no sediment, but yielding traces of albumin. When evacuated by 
incision, the mother cyst does not collapse readily, showing the exist- 
ence, not only of structural development, but of extensive peripheral 
infiltration. 

Evidence seems to point to the lymphatics as the chief avenue 
for the migration of these infectious elements, particularly when con- 
sidered with reference to their secondary manifestation. These para- 
sites have, however, the ability to penetrate the normal matrix; even 
after evacuation of the parent cyst, progressive invasion of the tissues 
may occur, until the peritoneum, the bladder, or even the intestine, 
is penetrated. 

Treatment. — This consists in the evacuation of the cyst whenever 
accessible. The cyst cavity should be opened freely, its walls should 
be curetted vigorously, after which it should be irrigated, first with 
25-per-cent solution of hydrogen peroxide, and subsequently packed 
with iodoform gauze. Drainage should be maintained until the cav- 
ity is thoroughly collapsed. If, however, the disease shows a tend- 
ency to progressive invasion of neighbouring structures, hysterectomy 
should be performed. When the infection is restricted to the uterine 
cavity, the expulsion of the cystic product generally results in the 
immediate recovery of the patient. 



CHAPTER XXVIII 

NEOPLASMS OF THE UTERUS 

Neoplasms of the uterus in general; varieties — Benign neoplasms — Fibromyomata: 
Causes, pathology, histology, secondary degenerations, diagnosis — Complicat- 
ing pregnancy — Treatment : Medicinal and electrical ; surgical, terms employed 
— Indications — Myomectomy — Supravaginal hysterectomy ; extra-peritoneal 
treatment of the pedicle — Panhysterectomy ; Reed's operation ; vaginal hyster- 
ectomy — Vaginal myomotomy — Extirpation of polypi. 

Neoplasms of the Uterus in General. — There is, perhaps, no organ 
of the body, in either the male or the female, which is so often the 
seat of tumour formation as the uterus. The intrinsic causes of 
neoplastic diseases of the womb are usually as obscure as of those 
of any part of the body. Embryonic inclusions, nutritive disturbances, 
irritation, and heredity, play a certain role as predisposing causes, yet 
their relation to tumour formation is by no means always demonstrable. 
Neoplasms of the uterus may be considered in relation to the differ- 
ent parts of the organ from which they arise. They may be divided 
according to their main clinical features into benign and malignant, 
or, according to their histology, into connective tissue and epithelial 
new growth. The connective-tissue tumours occurring in the uterus 
are the fibromyoma, the sarcoma, the endothelioma, and some mixed 
tumours of minor importance. The epithelial neoplasms comprise the 
adenoma malignum, the carcinoma, and the syncytioma malignum. 

Benign Neoplasms of the Utekus 

The tumours variously designated as fibroma, fibromyoma, fibroid 

or myoma of the uterus, are the most common neoplasms that develop 
in that organ. They are derived from the muscular coat and are com- 
posed of involuntary muscle cells and ordinary fibrous connective tis- 
sue, mixed in varying proportions. 

Their causes are various. The time of life when fibromyomata 
usually occur is that of sexual activity, but there have been reported 
a number of cases of this kind in children and in women after the 
climacterium. A good deal has been written upon the subject of 
the influence of prolonged virginity and abstinence from sexual inter- 
course, married life, abnormal sexual irritation, sexual excesses, mas- 
turbation, and so forth, upon the development of fibromyoma. Hered- 
396 



NEOPLASMS OF THE UTERUS 397 

ity has likewise been considered as a factor in the production of 
these neoplasms. Eace has been cited as a predisposing cause. It 
is well known that many American writers hold that myomata are 
much more common in the negro than in the Caucasian races. The 
statistics, the views and the theories of various experienced authors, 
are, however, so contradictory in many points, that we can not draw 
any definite general conclusions, and must for the time being leave 
open many questions as to the etiology of true fibromyoma. 

There is one class of fibromyomata, recently fulty described in a 
classical monograph by von Eecklinghausen, the adenomyomata, which 
in their origin clearly stand in a causal nexus with certain embryonic 
inclusions in the uterus. 

Yeit, in an article on the etiology and symptomatology of fibro- 
myoma, comes to the following conclusions: " So far as the common 
myomata (excluding the adenomyoma) are concerned, I hold that 
their origin from an embryonic inclusion ( c anlage ') has not been 
proved. It appears, however, that heredity plays a role therein, and 
one is also able to understand that irritation, acting chronically 
upon the uterus, may give rise to the formation of myomata: the 
modus operandi of the latter, however, is not yet clearly proved." 

Pathology of Fibromyoma Uteri. — Fibromyomata may arise from the 
muscularis of the, body as well as from that of the cervix. They vary 
a good deal in size and shape, and their particular position has a good 
deal of influence in this respect. They may be single, but more fre- 
quently they are multiple. One not infrequently finds in uteri re- 
moved for some cause, or obtained from the post-mortem table, very 
small myomata which have not given rise to any symptoms. On the 
other hand these tumours may attain an enormous size. Stockard 
saw in a coloured woman a myoma weighing 135 pounds, and Hunter re- 
ports the finding post mortem of a myoma weighing 140 pounds, while 
the rest of the body weighed 95 pounds. According to their seat and 
mode of origin, myomata are divided into submucous, interstitial, and 
subserous. 

Submucous myomata have their seat under the mucous membrane. 
They may be attached by a broad base to the muscularis or they 
may, and this is more commonly the case, become pedunculated and 
project polyplike into the uterine cavity. These myomata are gen- 
erally rich in blood vessels and muscle fibres and comparatively soft. 
They usually grow rapidly but rarely attain a very large size If by 
their growth they are forced down into the cervical canal they some- 
times assume an hourglass or dumb-bell shape. They have a marked 
tendency to undergo degenerative changes and to slough. The de- 
scent of these submucous myomata is often due less to their own 
neoplastic growth than to cedematous swelling in consequence of 
circulatory disturbances and to contractions of the uterus. These 
muscular contractions of the womb may sometimes bring about the 
spontaneous separation and delivery of a submucous myoma. 



398 



A TEXT-BOOK OF GYNECOLOGY 



Interstitial fibromyomata develop in the middle stratum of the mus- 
cularis uteri. They are, as a rule, well encapsulated, and can there- 
fore be easily enucleated. Only rarely is this variety intimately blended 
and connected by interlacing bundles of muscle fibres with the sur- 
rounding parts. If such interstitial tumours grow very large they may 
so stretch the parts of the uterus below that these form a kind of 
peduncle for the tumour. Such peduncles may in rare cases undergo 
torsion. 

The subserous fibromyomata are developed from the most super- 
ficial layers of the muscularis and project from the peritoneal sur- 
face. They are connected with the uterus by a more or less con- 
stricted short peduncle (Fig. 158). Smaller subserous myomata may 

also have a broad base, 
but the larger ones are 
generally pedunculated. 
The peritoneum firmly 
overlies the tumour and 
is intimately blended 
with it so that it can 
not easily be peeled off. 
These tumours, in con- 
quence % of their usual 
mode of attachment to 
the uterus, are generally 
more or less movable. 
The peduncle may un- 
dergo torsion or kinking. 
Subserous myomata are 
very liable to form adhe- 
sions with the neighbour- 
ing sexual organs, with 
the intestines, and with 
other structures. Myo- 
mata of this variety, 
springing from the lateral margins of the uterus, often grow into the 
broad ligament, separate its layers, and give rise to what is known as 
intraligamentous fibromyomata. 

Histology of Fibromyomata. — Histologically, the fibromyomata of 
the uterus consist of the same tissues as compose the muscularis of 
the uterus, namely, involuntary, smooth muscle fibres, and fibrous con- 
nective tissue. These two kinds of tissues are present in varying pro- 
portions. Some tumours may contain only a small amount of fibrous 
connective tissue, while in others it may so predominate that an almost 
pure fibroma exists. The muscle cells are arranged in bundles which 
cross each other and interlace with a great deal of variety and irregu- 
larity. Yellow elastic fibres are likewise found, also those particular 
cells known as " mast cells " and " plasma-mast cells." 




Fig. 158. — " They are connected with the uterus by a 
more or less constricted short peduncle." — Herzog. 



NEOPLASMS OF THE UTERUS 



399 



A particular variety of myoma is the adenomyoma. These tumours 
are ordinarily of moderate size, and are generally found near the serous 
surface in the posterior uterine wall and near the tubal angles. They 
are not encapsulated but shade off diffusely into the surrounding tis- 
sues and contain, besides the usual tissue elements of fibromyoma, 
epithelial structures. These latter are of a peculiar glandular type. 
There are generally seen a number of smaller ducts which communi- 
cate, like the teeth of a comb, with a larger duct. These epithelial 
structures are derivatives of remnants of the Wolffian duct and 
of the " urniere " of the AYolfhan body, which have been displaced 
in development, and which, as embryonic inclusions, give rise to 
the appearance of these 
peculiar new growths. 
The latter, from a histo- 
logical standpoint, must 
be looked upon as a mix- 
ture of connective tis- 
sue and epithelial neo- 
plasms. 

Fibromyomata often 
bring about changes in 
the whole uterus. The 
muscular coat, particu- 
larly if the myoma is so 
situated that it causes 
uterine contractions, is 
liable to undergo some 
hypertrophy character- 
ized by an increase in 
size of the individual 
muscle cells. The uter- 
ine mucous membrane 
shows either a glandular 
or an interstitial hyper- 
trophy. Herzog has also 
frequently observed an 
extensive cedematous in- 
filtration of the mucosa, 
with or without capil- 
lary interstitial hemor- 
rhages. Tubes and ova- 
ries are likewise affected 

when large myomata are present in the uterus. Endosalpingitis, sal- 
pingitis interstitialis, and oophoritis interstitialis with condensation of 
the ovarian stroma and round-cell infiltration, have been described. 

Secondary Degenerations of Myomata. — The secondary degenerations 
occurring in myomata are quite numerous. Atrophy sometimes occurs 




Fig. 159. 



A shell composed of lime salts." — Herzog 
(page 400). 



400 



A TEXT-BOOK OF GYNECOLOGY 



after pregnancy and after the menopause has been established, and 
under other conditions. Calcareous degeneration is common, and small 
particles of carbonates and phosphates of lime are very frequently found 
in myomata. Or there may be formed a solid stone or a shell com- 
posed of lime salts. Herzog examined a case of the latter kind. 
The specimen was obtained by an operation performed by Dr. M. L. 
Harris, on a woman seventy years old. It formed an elliptical mass 
about 14 centimetres long, consisting of a shell several millimetres 
thick, composed of lime salts (Fig. 159). Eeed removed from an 
aged patient a large interstitial fibroid of lateral development which 
had distended the broad ligament carrying the ovary and Fallopian 
tube of that side nearly to the umbilicus (Fig. 160). On opening the 
tumour a shell of calcareous matter and several foci of calcareous 




Fig. 160 (Reed). — " Eeed removed from an aged patient a large interstitial fibroid of lateral 
development which had distended the broad ligament, carrying the ovary and Fallopian 
tube of that side nearlv to the umbilicus." — Herzog. 



degeneration were found (Fig. 161). Fatty degeneration is also fre- 
quently seen; it often leads to the formation of cystic spaces in the 
tumour. Myxomatous degeneration, inflammation, necrosis, and slough- 
ing, are observed in fibromyomata. Amyloid degeneration has been once 



NEOPLASMS OF THE UTERUS 



401 



described by Stratz. Of malignant changes in a primarily benign myoma, 
the sarcomatous degeneration is the one most frequently met with. 
Von Eecklinghausen has seen several cases of carcinoma developing in 




Fig. 161 (Reed). — " On opening the tumour a shell of calcareous matter and several foci of 
calcareous degeneration were found."— Herzog (page 400). 



adenomyomata. The other mixed tumours, myochondroma and myo- 
osteoma, have been described, as well as rhabdomyoma of a sarcoma- 
tous type. 

Diagnosis. — These tumours are common in women of all races and 
of all ages, though more frequent in negroes and in women between 
the ages of thirty and forty years. Although found prior to puberty 
in rare instances, these growths are essentially incident to the men- 
strual period of life. Unmarried and sterile women are especially prone 
to this disease. 

Hemorrhage, while not invariably present, is a common and con- 
spicuous symptom of uterine fibromata. Profuse and prolonged men- 
struation is a marked and characteristic symptom. It is not uncom- 
mon to observe the most profound aneemia in consequence, the patient's 
skin assuming a waxy, yellowish hue, with anaemic heart murmur and 
profound general exhaustion. 

Pain is a conspicuous symptom in the majority of cases, and is 

the result either of pressure or of associated inflammatory disease of 

the Fallopian tubes and ovaries. The pain of pressure is determined 

more by the site of the tumour than its size. Thus, when growing 

27 



402 



A TEXT-BOOK OF GYNECOLOGY 



from the lower uterine segment and packing the pelvic cavity, the 
pressure on bowel, bladder, and nerve trunks, will be more severe than 
when the tumour is situated higher and rises freely above the brim 
of the pelvis. The ovaries and tubes are often found in a mass of 
inflammatory adhesions, and hydrosalpinx and pyosalpinx are not 
uncommon accompaniments of these tumours. Such complications may 
render small fibroid tumours painful in the extreme. Irritability of 
the bladder, and obstipation resulting from pressure of the growth, are 
common symptoms. 

The diagnosis of uterine fibromata is determined by recognising 
these symptoms in conjunction with careful physical examination of 
the pelvic organs. The bimanual touch will disclose the presence of 
a tumour, usually irregular in outline, and attached to the uterus. If 
the tumour is large, its firm consistence and nodular character may 
be detected by palpation through the abdominal parietes. Interstitial 
fibromata of symmetrical development may be mistaken for pregnancy 
(Fig. 162), an error more easily made from the fact that pregnancy 




Fig. 162.— " Interstitial fibromata of symmetrical development may be mistaken for preg- 
nancy." — McMuktry. 



not infrequently coexists with these tumours. The soft fibroma, espe- 
cially if cedematous, is distinguished with difficulty from an ovarian 
cystoma; and when cystic degeneration has taken place in the fibroma, 
diagnosis is impossible. Diagnosis is also practically impossible be- 
tween polycystic ovarian cystoma with general adhesions, and sym- 
metrical uterine fibroma. The clinical importance of these difficulties, 
however, is offset by the practical fact that both classes of tumours 
should receive the same treatment, viz.: removal by abdominal sec- 
tion. The vaginal portion of the cervix is rarely involved by fibroid 
changes in the uterus (Fig. 163). A small fibroid in the posterior uter- 



NEOPLASMS OF THE UTERUS 



403 




Fig. 163. — " The vaginal portion of the cervix is rarely- 
involved by fibroid changes in the uterus." — McMur- 
try (page 402). 



ine wall may be mistaken for retroflexion of the uterus; and such a 
tumour springing from the supravaginal cervix may be interpreted by 
the touch as inflammatory exudate. Such errors can be avoided only 
by careful study of the symptoms and history of individual cases, with 
painstaking bimanual examination after the bladder and bowel have 
been thoroughly emp- 
tied. Instrumentation 
per vaginam and digital 
exploration per rectum 
will rarely afford any 
special advantage over 
these established means 
of diagnosis, and unless 
done with skill and with- 
out force, will inflict 
pain and prove harmful. 

Pregnancy as a com- 
plication of uterine myo- 
mata occurs with suf- 
ficient frequency to de- 
serve special considera- 
tion. It is a matter of 
great practical importance to determine whether the life of the mother 
is endangered and operation consequently imperative; or, whether 
pregnancy and parturition may be safely completed without surgical 
intervention. While it is exceptional for a woman with large uterine 
myoma to become pregnant, numerous cases are recorded where the 
uterus has proved equal to the demand and carried the child to safe 
delivery near to or quite at full term. Under the stimulus of preg- 
nancy, with its increased blood supply, fibroid tumours grow rapidly; 
and small tumours hitherto unnoticed may become conspicuous. It 
is also true that, after delivery, fibromata participate in the retrograde 
changes in the uterus and shrivel to insignificant proportions. 

In certain exceptional cases, where the tumour arises from the lower 
segment of the uterus and fills the lower pelvis, thereby obstructing 
the passage of the child, the vital question of operative intervention 
must be met and determined. A case of obstructive myoma in 
which a successful operation was done by McMurtry is illustrated in 
Fig. 164 (Neiv York Medical Journal). Similar cases have been re- 
ported by Price, Hanks, Eeed, Vander Veer, Eoss, and others. This 
question should receive the most conservative consideration, for, in 
many instances, the uterus will bear its additional burden, and if the 
tumour is above the pelvic brim, or can be pushed above when labour 
comes on, safe delivery of a living child may be accomplished. The 
operative procedure in hystero-myomectomy, wherein pregnancy is a 
complication, does not differ in any essential particular from the opera- 
tion when performed in uncomplicated cases. 



404 



A TEXT-BOOK OF GYNECOLOGY 



Treatment: Medicinal and Electrical. — Various drugs have been 
recommended as either curative or beneficial in the treatment of fibroid 
tumours of the uterus. Such medicinal agents as ergot, gallic acid, 




Fig 164.—" A case of obstructive myoma in which a successful operation was done."- 

McMurtry (page 403). 



hydrastis, and some preparations of iron, have enjoyed favour in this 
capacity, being especially in repute for controlling hemorrhage, arrest- 
ing growth, and diminishing the size of the neoplasm. It can be clin- 
ically demonstrated that such agents do not yield the benefits claimed 
for them, while by impairing digestion and producing constipation they 
are harmful in their general influence upon the system. Fibromata 
of the uterus are so constantly influenced by circulatory changes in 
the pelvic viscera, such as menstruation and impaired resistance, that 
errors of judgment may readily be made by the overconfident observer. 

The results formerly claimed for deep injections of ergot, and more 
recently for electrical applications, have proved misleading and have 
resulted in the discarding of these remedies. Such treatment is not 
only inefficient, but positively harmful, in consequence of the constant 
localized peritonitis produced thereby. The perfected operative treat- 
ment (Fig. 165) of modern surgery has taken the place of all treatment 
both with drugs and electricity. (See chapter on General Therapeutics.) 
When the tumour is of small size and unaccompanied by hemorrhage 
or other serious symptoms, no treatment whatever will be required. 
The requirements of individual cases must guide the practitioner in 
the determination of these important considerations. 

In approaching the surgical treatment it is well to have a distinct 
understanding of some of the terms employed. The terms myomectomy 
and hystero-myomectomy both indicate operative procedures for the re- 



NEOPLASMS OF THE UTERUS 



405 



moval of fibroid tumours of the uterus. The former term is applied 
to the operation in which the tumour or tumours are removed and 
the uterus preserved; the latter indicates the removal of the uterus in 
part or in whole along with the tumour. Hysterectomy properly 
denotes removal of the uterus without regard to the presence of neo- 
plastic formations, but is habitually used as synonymous with the term 
hystero-myomectomy in treating of fibroid tumours. Hysterectomy 
may be partial or complete. The term supravaginal hysterectomy is 
applied to amputation of the uterus at the internal os, leaving a cer- 




Fig. 165. — "The perfected operative treatment of modern surgery has taken the place of all 
treatment both with drugs and electricity." — McMuktry (page 404). 



vical pedicle (Fig. 166); complete hysterectomy, involving the removal 
of the entire uterus including the cervix, is often termed panhyster- 
ectomy. 

Indications for Operation. — The operations for the removal of 
fibroid tumours have reached a stage of perfection that elicits admira- 
tion and commands confidence. Since we have learned to control 
hemorrhage in these operations, the indications for the operation have 
advanced beyond the limitations that obtained a few years since. Those 
who have practised the removal of the ovaries for the reduction in 
size of a myomatous tumour, or for the purpose of staying the growth 
of such a tumour, know well that the convalescence in such cases 



406 A TEXT-BOOK OF GYNECOLOGY 

is fraught with serious complications that give the operator a great 
amount of anxiety. As a consequence of the rapidity with which a 
circulatory change takes place in these tumours after ablation of the 
ovaries, suppuration occasionally sets in, the tumour begins to break 




Amputation of the uterus at the internal os, leaving a cervical pedicle." — 
McMurtry (page 405). 

down, and the patient becomes desperately ill. An experienced oper- 
ator, therefore, will be more anxious to remove fibroid tumours entirely 
than to remove the ovaries alone. It is, therefore, becoming a serious 
question as to which operation in skilled hands, performed according 
to modern methods, is the more serious of the two. That is, whether 
the operation of abdominal hysterectomy or myomectomy, when per- 
formed for the removal of moderate-sized tumours, is more serious than 
the removal of the ovaries from their position alongside such tumours'. 
Indications for the removal of such tumours are, rapid growth, grave 
hemorrhages from the uterus, ascites, compression on important organs, 
suppuration or degeneration of the tumoUr, and pregnancy under 
certain circumstances. When the tumour grows rapidly it may undergo 
malignant degeneration, or become cedematous. Small pedunculated 
tumours are not likely to be reduced in size as a consequence of 
the removal of the ovaries, and when these tumours give rise to 
pressure symptoms their removal is necessitated. 

General Considerations. — The removal of small pedunculated 
growths is a simple matter. The uterus, ovaries, and tubes, are left 
intact and the patient has her sexual organs practically uninterfered 
with. There is a class of cases in which we may remove the tumour 
by a process of enucleation and leave the uterus intact. We have 
certain tumours deep down in the pelvis or in the broad ligaments 
that require enucleation. In some of these cases it is found impos- 
sible to control the hemorrhage without removing the entire uterus 
and we must always be prepared to go on and complete the more 
extensive operation. In all these operations it is important that we 
should be able to control the hemorrhage with ease as the operation 
proceeds. The elastic ligature is perhaps the most valuable aid we 



NEOPLASMS OF THE UTERUS 407 

have. This should only be used temporarily, and be abandoned after 
the hemorrhage has been checked by other means. A few years since 
the serre-ncend of Koeberle was used, but this is now very largely dis- 
carded. The elastic ligature is passed around the cervix and broad 
ligaments, and is held in position by means of an artery forceps placed 
upon it after it has been pulled taut. It does not require very much 
pressure to control the hemorrhage. 

Myomectomy. — For removing the pedunculated fibromata the elas- 
tic ligature is placed in position, a needle armed with a double silk 
ligature is then passed through the pedicle, and the pedicle is tied 
in half sections. If the pedicle is very large and thick it is seized and 
compressed by clamp forceps while the tumour is cut off, and care 
is taken to leave a collar of peritoneum and capsule large enough 
to permit approximation across the face of the stump. The clamp 
is then removed and the furrow is pierced with a needle carrying a 
silk suture that is tied in several sections. The edges of the stump 
above are then approximated by interrupted sutures. The provisional 
elastic ligature is next removed, and if there is much oozing about 
the sutures, a few deeper ones must be placed. When large vessels can 
be seen during the section of the pedicle they are tied separately. 
The pedicle must not be returned to the abdomen until after all 
oozing has ceased. If the oozing continues, sufficient time must be 
given to permit of its arrest by the adoption of appropriate methods; 
and if it does not then cease something further must be done. It 
occasionally happens that the uterus, itself, will require removal be- 
fore the hemorrhage can be controlled. Too much time and blood 
must not be lost before the operator determines this fact. 

Indications. — When a tumour is single, or when there are but two 
or three nodules, the enucleation of interstitial myomata may be car- 
ried out. ~\Ye must have our patients or their friends understand, how- 
ever, that if it is impossible to control the hemorrhage the entire 
organ must be removed. Very large single myomata of the interstitial 
variety may be removed by myomectomy (Fig- 167). 

Some operators have recommended the removal of both ovaries if 
other fibrous nodules are present and beyond our reach, but it seems 
only reasonable to suppose that, under such circumstances, it would 
be better to remove the uterus in the ordinary way by the method 
of supravaginal amputation. Unless the operation is combined with 
castration there is always a danger of the development of a second 
tumour that may be overlooked at the time of the primary operation. 
To avoid this danger it is necessary to remove both ovaries. As a con- 
sequence, this operation would seem to have but a limited field in 
cases in which it is not desirable to perform supravaginal amputation; 
in other words, it becomes an operation of expediency. 

Many a young married woman may have a fibroid tumour that 
requires removal. She is willing to have the tumour removed, but she 
is not willing to submit to the more radical operation of removal 



408 



A TEXT-BOOK OP GYNECOLOGY 



of uterus, ovaries and tubes. A subsequent pregnancy may, it is true, 
endanger her life owing to the weakness produced in the uterine 
wall by the enucleation of a myoma, but if she is willing to take her 
chances it seems but fair that we should perform the operation for 
her in preference to that of supravaginal hysterectomy. 




Fig. 167 (Reed). — " Very large single myomata of the interstitial variety may be removed by 
myomectomy." — Boss (page 407). 



Operation. — It is a well-known fact that these myomata bleed from 
the capsule and do not bleed from the central core, or tumour proper. 
To control the hemorrhage, therefore, it is necessary to compress the 
capsule. The elastic ligature when applicable should be placed in situ 
before the primary incision is made into the tumour capsule. These 
incisions should be made in such a way as to wound the small arterioles 
and not the large trunks. Incisions in the median line are less 
liable to bleed than those placed' to either side. The incision must 
go through the capsule to the tumour mass (Fig. 168), and must be 



NEOPLASMS OF THE UTERUS 



409 



sufficient to permit the enucleation of the tumour. Enucleation should 
be done by a process of tearing and not of cutting; the vessels will, 
as a consequence, bleed less. A scoop, similar to that used for the 
removal of gallstones, or stones from the urinary bladder, may be 
used as an enucleator. Special instruments have been constructed for 
this purpose, but are rarely needed. The finger and the handle of 
the scalpel answer admirably as enucleators. Connective tissue will 
be found dipping down here and there between the meshes of the 
tumour and separating its outer wall from the inner surface of the 
capsule. It is in this connective tissue that the enucleation must 
be carried out. 

After the tumour has been removed, it is wise temporarily to 
loosen the elastic ligature placed around the cervix, for the purpose 
of tying vessels that may be seen to bleed specially. In this way 




Fig. 168 (Keed).— " The incision must go through the capsule to the tumour mass."— Ross 

(page 408). 



all the large vessels may be tied with catgut ligatures. The elastic 
ligature can be again tightened and the tissues stitched firmly by 
means of layers of continuous catgut sutures. Finally, the capsule 
wall is brought firmly together by a row of interrupted sutures or 
by a continuous suture of formalinized catgut (Fig. 169). The elastic 



410 



A TEXT-BOOK OF GYNECOLOGY 



ligature is finally dispensed with, and the parts are watched until all 
bleeding has ceased. It should be a fixed rule not to return the 
uterus to the abdominal cavity unless bleeding has ceased. One of 
the great dangers accompanying the operation is hemorrhage into the 
abdominal cavity after the return to it of the uterus, and after the 
relaxation of the blood vessels has taken place owing to the cessation 
of the tension. The uterine canal may be laid bare. When this 
is the case it is advisable to place a small strip of gauze down through 
the cervix and pack the cavity left after the removal of the tumour 




Fig. 169 (Reed).— " Finally the capsule wall is brought firmly together by . 
suture of formalinized catgut."— Ross (page 409). 



continuous 



(Fig. 170); or drainage may be effected by means of Reed's self -retain- 
ing tube passed from the tumour nest out through the cervix and 
vagina (Fig. 171). 

Supravaginal Hysterectomy.— The difficulties to be encountered 
during the operation depend upon the location of the tumour and 
the extent of the adhesions. The important fact to be remembered 
is that the blood supply is obtained through the uterine and ovarian 
arteries. These arteries can readily be located by means of the thumb 
and forefinger with gentle pressure. The pulsations can be readily 
felt. When the blood vessels have been located it is easy to dissect 
down to them, provided we do not cut, but dissect with the handle 
of the scalpel, into the cellular tissues of the broad ligament, 
taking care to avoid the large veins found in these cases. The ves- 
sels can be tied either en masse or separately as they are found. 
Just as we place a tourniquet upon the femoral artery before ampu- 



NEOPLASMS OF THE UTERUS 



411 



tating the thigh, so should we place our ligatures upon the two uterine 
and two ovarian arteries before attempting to amputate the uterus. 
If hemorrhage then occurs we may rest assured that we have failed 




Fig. 170 (Reed).— "The uterine canal may be laid bare; . . . place a small strip of gauze 
down through the cervix, and pack the cavity left after the removal of the tumour." — 
Eoss (page 410). 



in properly securing the vessels. Blood will flow from the upper or 
tumour side of the cut, but the proximal side will be almost dry 
if the vessels have been properly tied. If the uterine cavity is opened, 







Fig. 171 (Reed).— " Or drainage may be effected by means of Reed's self-retaining tube 
passed from the tumour nest out through the cervix and vagina."— Ross (page 410). 



412 A TEXT-BOOK OF GYNECOLOGY 

it is wise to disinfect it with a little pure carbolic acid before stitch- 
ing up the stump. Some operators pass down a small wick of gauze 
through the cervix into the vagina to admit of drainage. The great 
advance that has been made in this surgical procedure is due to the 
fact that we depend entirely upon ligation of the large blood trunks 
supplying the tumour for the control of hemorrhage, and that we 
have done away with the temporary or permanent clamp. Many 
operators scarcely ever use these aids to hemostasis. In performing 
this operation, great care should be taken to prevent loss of blood, 
to economize time, and to avoid subsequent hemorrhage. Loss of blood 
during the operation greatly increases the rapidity of the patient's 
pulse; loss of time increases the shock; and loss of blood after the 
operation will often prove fatal. It is never well to sacrifice thor- 
oughness for speed, but there is a happy medium to be obtained. 
There is no operation in the whole field of surgery that requires more 
deliberation. 

It is scarcely necessary to describe the operation as performed a 
few years since by means of the permanent Koeberle serre-nceud. We 
rarely see the large ovarian tumours that were common twenty or 
thirty years ago, because such tumours are now removed when small. 
So it is with the myomata; they are removed much earlier owing 
to the diminished risks of operation. 

Technique of Supravaginal Hysterectomy. — The usual precautions 
are taken in preparing the patient. A purgative is given the day 
before, an enema on the morning of the operation, the skin over the 
abdomen is thoroughly disinfected, and the armamentarium of instru- 
ments required laid out in a convenient place, after having undergone 
thorough sterilization. The patient must be well wrapped up on the 
operating table to prevent chilling of the body surface. 

The instruments required are: scalpel; large and small compression 
forceps; long-bladed clamp forceps; pedicle needle for transfixion; re- 
tractors; uterine sound; female bladder sound; heavy silk; catgut in 
various sizes; curved needles, various sizes; needles for closing abdomi- 
nal wound; scissors; rubber tubing for elastic ligature; serre-noeud 
with hysterectomy pin; glass drainage tube. 

The abdomen is now opened by a free incision. If adhesions are 
encountered great care must be taken in dealing with these, as the 
tumour surface will bleed at the points from which adhesions are 
removed. It is much wiser, in dealing with these adhesions, to ligate 
them in two places and cut them away, leaving a ligated portion 
still adherent to the tumour. If intestine is so intimately adherent 
to the tumour as to prevent this procedure, it must be separated with 
as light a touch as possible. Hot cloths placed over the spots from 
which adherent intestine has been removed will control the hemorrhage 
while it is left in situ. The tumour is now raised out of the abdomen. 
Sponges are packed down above it to retain the intestines, and, if 
the incision has been a long one, it is wise to draw its edges together 



NEOPLASMS OF THE UTERUS 413 

above the tumour by means of one or two silkworm-gut sutures. In 
this way the intestines are kept in the abdomen and out of the way. 

We must now outline the bladder limits. This is done by means 
of a sound passed into the bladder by an assistant. This sound is 
pushed well upward until the upper confines of this organ are accu- 
rately determined. Small pressure forceps are then placed a little 
above this line to act as guides to the position of the bladder. The 
peritoneum is now incised over the front of the tumour, care being 
taken not to go deeper than the peritoneum, because any incision of 
the tumour capsule will cause hemorrhage. By means of the finger 
and the handle of the knife, the peritoneum, with the bladder, can 
then be easily entirely stripped down from the front of the tumour. 
The connective tissue lying immediately beneath it permits of this 
loosening process. There is thus no danger of wounding the bladder 
by the puncture of the pedicle needle. 

The ovarian artery on one side must now be felt for and secured, 
either by a ligature en masse, or by a single ligature. If the single 
ligature is used the veins must also be tied by means of another liga- 
ture. These veins are always very much enlarged. A forceps is now 
placed on the tumour side of the mesentery of the tube to control 
the regurgitant hemorrhage; and the mesentery of the tube, together 
with the broad ligament at this point, is cut across. Should any bleed- 
ing point be found, it is easy to control this hemorrhage by the appli- 
cation of another forceps. The connective tissue close to the tumour 
and inside of the veins of the pampiniform plexus can now be seen and 
pushed into with the finger. If this process is continued, one may grope 
down farther until the uterine artery, whose presence is made known 
by its pulsations, is found, and this artery may be followed well down 
to the cervix and may be there ligated, either en masse, or in a 
separate ligature. When the ligature is placed, care must be taken 
to pass the pedicle needle close to the cervix uteri and the loop 
should be carried upward and outward instead of outward, before it 
is finally tied. In this way we avoid inclusion of the ureter. A 
similar procedure is next followed on the opposite side. The blood 
supply to the tumour is now shut off, except what little it gets through 
the azygos vagina? artery and another small vaginal branch in front. 
The amputation of the tumour is next effected with a few sweeps of 
the knife. It occasionally happens that one or two vessels can be seen 
spouting from the anterior or posterior surface of the stump. These 
may be tied with small catgut ligatures. If, however, there is nothing 
but a slight general oozing, the operator will proceed to the next steps 
of the operation for the control of this hemorrhage. 

By means of a small curved needle that cuts on the flat, the wound 
is stitched up from the bottom with continuous catgut sutures; each 
stitch is pulled tightly and held taut by the assistant until the next 
stitch is taken. In this way the stump is gradually built up and puck- 
ered in until finally the outermost edges are approximated above just as 



414 A TEXT-BOOK OF GYNECOLOGY 

the two flaps are brought together after an amputation of the leg. 
The peritoneum is stitched together over the surface, and this stitch- 
ing is continued on outward over each broad ligament so that nothing 
but peritoneum can be seen when looking into the pelvic cavity. 

A little hemorrhage may have been found about the downward 
dislocated bladder. If any vessels persist in oozing here they may be 
controlled with small catgut sutures. The mere approximation of 
the bladder back into its old position, produced by the suture of the 
peritoneal edges before and behind the stump, is usually sufficient to 
control all hemorrhage. There is sometimes a little oozing for three 
or four hours after the patient has been placed in bed, and on this 
account many operators place a glass drainage tube in the cul-de-sac 
of Douglas from above or from below. If placed below, the vagina 
is packed with iodoform gauze to keep the drainage tube in situ. 
If the drainage tube is placed in the cul-de-sac of Douglas from above, 
it should be removed within a few hours after the operation. Con- 
siderable blood will drain from it for two or three hours, and then 
the quantity rapidly diminishes. 

The ligatures used on the ovarian and uterine arteries may con- 
sist of either catgut or silk. Some operators are not satisfied to use 
catgut owing to the difficulty experienced in tying it with sufficient 
firmness, unless the gut is of such a thickness as to make it difficult 
to completely sterilize it. Silk, if used, should not be any heavier 
than is necessary to accomplish the purpose for which it is intended. 
If the silk is of the first quality a much smaller strand can be used than 
if it is of an inferior quality. 

If hemorrhage still continues after the stump has been stitched 
together in the manner described, it is sometimes necessary to transfix 
lower down and tie the stump with very strong thread into two 
sections. This procedure can, however, scarcely be called for if the 
arteries have been properly ligated in the commencement of the opera- 
tion. When such hemorrhage occurs, the arteries may be sought for 
and an effort made to find the presence or absence of pulsation beyond 
the ligatures. It may even be advisable to throw another ligature 
around any or all of the vessels to insure their constriction, as the 
placing of a loop about the whole pedicle may produce sloughing of 
the tissue. Ross has seen this occur in one case. 

Extra-peritoneal Treatment of the Pedicle. — If it is decided to treat 
the pedicle according to an extra-peritoneal method, the technique 
of the first part of the operation is exactly similar to that just de- 
scribed. The vessels are ligated and the wire clamp is then passed 
down around the pedicle, inside of and above the broad ligaments 
that have now been divided and pushed away. A single or double 
pin is then pushed through the stump to hold it outside the abdominal 
cavity and to keep the wire from slipping off the pedicle. The wire 
is then tightened up and the tumour rapidly removed. The wound 
is next closed about the stump so that the peritoneal surface of the 



NEOPLASMS OF THE UTEBUS 415 

stump comes in contact with the parietal peritoneum. The perito- 
neal cavity is thus shut off by adhesions in a few hours. The 
bladder must be carefully dissected down and pushed out of the way, 
in order that injury to the bladder and ureters by the wire of the 
clamp may be avoided. These unfortunate accidents have occurred 
on several occasions. Intestine must also be kept well out of the way. 

The stump is now tanned with a solution of perchloride of iron 
and glycerine, and covered with strips of dry lint. The serre-noeud 
is tightened frequently, and the pedicle sloughs off about the twelfth 
day, leaving a granulating surface that requires several weeks to 
heal. 

The so-called mummification of the stump is not of very great 
importance. Even though the stump mummifies, the tissues under- 
neath frequently suppurate. 

Another extra-peritoneal method of dealing with the pedicle is that 
by which it is transfixed and tied with chain suture, and then fastened 
in the abdominal wound without the use of any clamp. As a con- 
sequence of the position of the pedicle, this method prevents union of 
the abdominal incision by first intention and permits of a subsequent 
hernia through the abdominal parietes. There is nothing to be gained 
by leaving the pedicle in this situation. It was supposed that it could 
be readily lifted up and hemorrhage could be easily controlled, but 
this has proved to be an unnecessary precaution now that the ligation 
of the vessels is better understood. A great deal of this sort of surgery 
can, with profit, be relegated to the past though it has all served a 
useful purpose. 

The ideal operation, described above, is all that can be required 
for the removal of fibroid tumours where they occupy a position in 
the fundus, or press outward into the broad ligament or into the 
pelvis. All can be removed by this procedure with ease and safety by 
experienced operators. At this stage of our knowledge, it is useless 
to recount the different methods adopted by different operators during 
the past ten or fifteen years. Most of these methods have been dis- 
carded, or. if they have not been discarded, they should have been. 

Panhysterectomy, as the name implies, means the complete extir- 
pation of the uterus. In practice, the ovaries and Fallopian tubes are 
generally, although not always, removed with the uterus. A number 
of operators recommend in this, as in other operations for the removal 
of the uterus, that an ovary, if entirely healthy, be left in situ, for 
the purpose of maintaining the menstrual molimen and of mitigating 
the nervous symptoms that frequently follow complete ablation of the 
genital apparatus. 

The technique of this operation, as practised by Eoss, is similar 
to that described for the removal of the myomatous uterus by supra- 
vaginal amputation. The cervix may readily be removed after the 
tumour has been cut awav and is no longer obstructing the view. The 



416 



A TEXT-BOOK OF GYNECOLOGY 



vessels supplying the cervix are the same as those supplying the 
vaginal wall at its junction with the cervix, provided that the blood 
supply from the uterine arteries has been cut off. We may, therefore, 
expect to find the azygos vaginae artery spouting when the vaginal 




Fig. 172. — " The small clamps attached to the uterus are now hooked up by two fingers of the 
left hand, by which traction is made." — Reed (page 417). 



septum is cut through at its junction with the cervix in the neigh- 
bourhood of the cul-de-sac of Douglas. No vessels of importance will 
bleed on either side, but another small branch or two will be found 



NEOPLASMS OF THE UTERUS 



417 



spouting in the vaginal septum, where it is separated from the uterine 
neck in front. These vessels can he readily ligated with catgut. 

Reed's operation of panhysterectomy is as follows: All adhesions 
of the uterus and its appendages are first broken up and the uterus 
is lifted up into the abdominal incision. In some cases this manipula- 
tion can be done so satisfactorily with the patient upon her back that 
it is unnecessary to put her in the Trendelenburg position, although 
in most cases the latter posture is not only desirable but necessary. 
The broad ligament is then clamped upon one side, just beneath the 
ovary and Fallopian tube, the clamp extending from the margin of the 
broad ligament to the side of the cervix. Another and smaller clamp 
is now placed on the broad ligament parallel with the previous clamp 
but a quarter of an inch nearer to the uterus. The broad ligament 
is then divided between the clamps, from its edge to the side of 




Fig. 



173. — " The uterine arteries which can be seen and clamped as soon as they are 
reached." — Reed. 



the cervix; the broad ligament on the other side, is similarly clamped 
and incised. The vesical fold of the peritoneum is now dissected away 
from the front of the uterus, as is the peritoneum covering the pos- 
terior side of the organ. The small clamps attached to the uterus 
are now hooked up by two fingers of the left hand, by which trac- 
tion is made (Fig. 172). As the uterus is drawn away from the vagina, 
the dissection is made by means of the scissors held in the right hand. 
Care should be taken in making this dissection to avoid wounding the 
uterine arteries, which can be seen and clamped as soon as they are 
reached (Fig. 173). From this time on, the dissection should be carried 
even more closely to the cervix, dividing the cervical tissues sufficiently 
to leave a slight ring in situ after the cervix is withdrawn. If this 
precaution is not taken, there is liability of wounding the azygos vagina? 
28 



41 



A TEXT-BOOK OF GYNECOLOGY 



artery, the hemorrhage from which, while controllable, is embarrassing. 
When the vagino-cervical juncture has been reached, the point of the 
closed scissors may be thrust through into the vaginal canal. After 
this preliminary opening, the remaining division of the vaginal mucosa 
is accomplished with facility. The ovarian and the uterine arteries 
upon either side are next tied individually by means of formalinized 
catgut. All clamps are now removed, and the field of operation is 
inspected to make sure of complete arrest of the bleeding. If this is 
duly controlled, a piece of sterilized gauze is packed into the vagina from 
above, the upper part of the pack coming within and above the cut 
margins of the vaginal mucous membrane. The peritoneal margins 
are stitched together by means of a continuous catgut suture. Finally, 
the toilet of the peritoneum is made by means of dry sponging, and 
the incision is closed by laminated sutures. (See Abdominal Section.) 
The specimen removed will show a complete uterus with the append- 
ages and the exact area of the dissection (Fig. 174). 

If it is desired to use the angeiotribe for hemostasis, it can be 
applied just beneath the temporary clamp, which is then removed. 




Fig. 174. 



The specimen removed will show a complete uterus with appendages and the 
exact area of the dissection." — Reed. 



Care should be taken that the end of the angeiotribe shall embrace 
the uterine artery within its clasp (Fig. 175). The instrument should 
be left on a few minutes, when it can be applied similarly to the 
other side. Doyen, who invented the angeiotribe, does not trust it 



NEOPLASMS OF THE UTERUS 



419 



alone to control hemorrhage under these circumstances, but applies a 
supplementary ligature, asserting as a sufficient advantage for using 
the instrument that it diminishes the volume of the tissues and renders 
less liable slipping of the pedicle. The electric clamp of Skene may 




Fig. 175. — " If it is desired to use the angeiotribe for hemostasis, it can be applied just beneath 
the temporary clamp, which is then removed. Care should be taken that the angeiotribe 
shall embrace the uterine artery within its clasp." — Reed (page 418). 



be similarly employed (see Hemostasis), but whether forcipressure or 
heat is applied for hemostasis, the peritoneal margins should be stitched 
together to avoid retraction. 

The advantages of panhysterectomy are (a) the contamination of 
the field of operation, which is so liable to happen as the result of 
extension of infection from the endocervium in cases of supravaginal 
amputation, does not occur; (b) drainage by the vagina is easily and 
thoroughly accomplished; (c) with care in avoiding the azygos vaginas 
artery, hemostasis is readily secured and safely maintained. The re- 
sulting condition of the pelvic diaphragm is one of equal, if not greater, 
strength than that secured by the supravaginal operation; (d) if the 
technique above described is carefully followed, the operation is done 
with greater facility than are others devised for the extirpation of 
the uterus; (e) myomatous uteri of considerable magnitude may be 
removed, en masse, by this means (Fig. 176). 

Vaginal hysterectomy is sometimes practised for the removal of 
small diffuse myomata of the uterus, associated with persistent and 



420 



A TEXT-BOOK OF GYNECOLOGY 



uncontrollable hemorrhage. The technique of the operation does not 
differ from that described in connection with malignant neoplasms of 
the uterus. (See Vaginal Hysterectomy.) 

Vaginal Myomotomy. — (a) Enucleation (technique). — The tumours 
most appropriate for enucleation are small and medium-sized, single 




Fig. 176.—" Myomatous uteri of considerable magnitude may be removed, en masse, by this 

means." — Reed (page 419). 

submucous tumours that are not pedunculated, and interstitial tumours 
distinctly encapsulated and projecting well into the cavity; also large 
tumours projecting into the os or partly extruded from the same. 
Very large tumours, if removed by vaginal myomotomy, are best ex- 
tirpated by morcellement or by combined morcellement and enucleation. 
The cervical fibroids requiring enucleation are of rare occurrence. 
They may be extirpated as a rule without difficulty. After exposing 
them by means of a Sims's speculum and retractors, an ample incision 
is made through the covering of the tumour, which covering is sepa- 
rated from the tumour with the finger or handle of the knife (Fig. 177); 
then the uncovered portion of the tumour is seized with a strong volsella 
forceps and traction upon, and rotation of, the neoplasm is made, while 



NEOPLASMS OF THE UTERUS 



421 



the finger is inserted between the tumour and its envelopes, to sever its 
cellular connections. Should there be any dense bands of tissue ex- 
tending from the tumour into the underlying tissues, they should be 
severed with scissors. Emmet's right-hand, lesser-curved, blunt- 
pointed scissors, serve as an excellent substitute for the ringer, and 
are ready at hand if needed to sever any bands. No great difficulty 
presents and there is as a rule little hemorrhage. If needed, hot- 
water irrigation and packing the cavity with gauze will arrest bleeding. 

When the neoplasm 
to be enucleated is situ- 
ated within the uterine 
cavity, it is a matter of 
the first importance that 
the os be widely dilated. 
This may be effected by 
laminaria tents, the steel 
dilator, or b} r lateral 
incisions of the cer- 
vix. The last method is 
preferable. The various 
steps of the operation 
may be stated as follows: 
The patient is placed in 
the dorsal position, with 
legs in holders or feet se- 
cured in the high stir- 
rups, and with buttocks 
projecting slightly be- 
yond the edge of the 
table. She has been pre- 
viously prepared. Wash 
out the vagina again with 
a bichloride solution; re- 
tract the perineum with 
a self - retaining specu- 
lum, preferably a Jones's 
with a short blade. 
Now seize the anterior lip 
of the cervix with bullet 

forceps and pull down the uterus. Incise the os with scissors or knife. 
Examine the tumour to determine its size and location, make ample 
incision through its covering over the most dependent accessible part. 
Separate the envelopes from the tumour for a short distance, and 
seize the neoplasm with a strong short-tined volsella or liuseux for- 
ceps. Now proceed as indicated in describing the method of enucleat- 
ing the cervical fibroid. Thomas's serrated spoon saw (Fig. 178) will 
often be found serviceable in loosening the tumour attachments. Con- 




Fig. 177. — " An ample incision is made through the cov- 
ering of the tumour, which covering is separated from 
the tumour with the finger or handle of the knife."— 
Dunning (page 420). 



422 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 178. 
" Thomas's 

serrated 
spoon saw." 
— Dunning 
(page 421). 



siderable force may be required to dislodge the tumour. Strong trac- 
tion may be employed, but the danger of lacerating the uterine walls 
or producing inversion of the organ, must be borne in mind. If the 
tumour is too large to be delivered whole, it may be cut 
into sections and removed piecemeal. 

(b) Morcellement. — When the tumour is very large, this 
method may be employed in preference to enucleation. 
Emmet is given the credit of priority in describing and 
putting into execution a systematic method of vaginal 
myomotomy by morcellement. It has often been denomi- 
nated Emmet's traction method, but it comprises most of 
the essential features of what is known to-day as vaginal 
extirpation by morcellement. It differs from enucleation in 
that after dilatation of the os, no effort is made to divide 
the capsule of the tumour, and 
sections of the neoplasm are 
made in the vagina. The neo- 
plasm is seized at its lower por- 
tion with strong hooks or vol- 
sella forceps and forcibly drawn 
downward. As it descends into 
the vagina, portions of the tu- 
mour are cut away and removed, 
the remaining portion is again seized and 
powerfully drawn upon, and once more the 
presenting part is cut away. And so the 
process is carried on, until finally the base 
of the tumour is reached. It will now be 
observed that, in consequence of the power- 
ful traction, a pedicle has been formed 
which, in some of Emmet's cases, was no 
larger than the index finger and consisted 
of the coverings of the tumour. This base 
is severed and the last of the tumour is re- 
moved. The traction upon the tumour 
stimulates uterine contraction, so that as 
the tumour descends, the uterus follows, 
closely encircling the neoplasm. If neces- 
sary, the descent of the uterus may be aided 
by pressure upon the fundus from above the 
pubes. Injections of hot water into the 
cavity of the uterus may be made if needed 
to stimulate contraction or to arrest hemor- 
rhage. In case of profuse hemorrhage dur- 
ing the process of extirpation, the tumour should be removed as quickly 
as possible, hot- water injections employed, and later, if necessary, gauze 
packing. 




Fig. 179. — Pean's forceps for mor- 
cellement. — Dunning (page 423). 



NEOPLASMS OF THE UTERUS 



423 



Pean's method of morcellement differs little in principle from Em- 
met's, the chief differences being in the use of specially devised instru- 
ments (Fig. 179), the preliminary severing of the vaginal and other 
attachments of the cervix as high as the lower margin of the tumour, 
and the excision of the lips of the cervix and application of pressure 
forceps to bleeding vessels within the uterine cavity, if the hemorrhage 
is profuse. 

The following is a brief summary of Pozzi's (Medical and Sur- 
gical Gynecology, vol. i, pp. 267-272) excellent and elaborate descrip- 
tion of Pean's method: 

1. Liberate the cervix by circular incision. Check hemorrhage by 
application of pressure forceps. 

2. Incise the cervix bilaterally from the cervical canal. Incise the 
lower segment of the uterus if necessary to the level of the tumour. 

■ 3. Seize the anterior and posterior lips of the uterus with forceps 
and draw the organ toward the vaginal outlet. 

4. Seize the most accessible portion of the tumour with forceps, 
drag it downward and cut off a section. Seize the accessible portion 
again, drag downward and cut away another piece. Eepeat this pro- 
cedure until finally the remainder of the tumour comes within reach. 
Now, if pedunculated, sever the pedicle and remove the last of the 
tumour. If more easily effected, enucleate the remaining mass. Search 
for other tumours; if any are found, extirpate them in like manner. 
If there is no hemorrhage, irrigate the uterine cavity with a hot anti- 
septic solution and place one or two strips of gauze for drainage. 
Stitch the incised cervix. Stitch the incised vaginal walls to the 
cervix and pack the vagina lightly with gauze. 

If there is prolonged hemorrhage not checked by hot irrigation, 
excise the lips of the cervix, draw the uterus down to the vaginal 
outlet, mop out the uterine cavity, seize the bleeding vessels with 
long catch forceps and pack the uterine cavity lightly with gauze. As 
a final step, stitch the lower end of the uterus to the incised vaginal 
walls. 

Both Emmet's and Pean's operations in cases of large tumours 
are formidable and may in many instances be rejected in favour of 
vaginal or supravaginal hysterectomy. They are contraindicated 
when the uterus contains several tumours, and when there is suppura- 
tive disease of the uterine adnexa. 

In view of the fact that foci of fibroid development may, and 
often do, exist in such size and localities as to defy detection in the 
remaining uterine wall; and in view of the frequent recurrence of 
fibromyomatous growths in uteri which have been subjected to myo- 
mectomy, many operators, with good cause, reject the latter operation. 
It is undeniable that hysterectomy is to be preferred in the majority 
of cases. It is argued that myomectomy is always a serious operation, 
that, as already stated, it often fails to bring the patient immunity, and 
that there is difficulty in detecting other commencing growths. This 



424 A TEXT-BOOK OF GYNECOLOGY 

is all avoided by hysterectomy, the immediate dangers from which are no 
greater than from myomectomy. It is true that a few women have 
conceived and borne children after myomectomy, but this result is 
rare; sterility or, in the event of conception, abortion may be set 
down as of commoner occurrence. 

Extirpation of Polypoid Growths from the Uterus. — The method of 
removal of a small polypus attached at or near the external os is 
simple. With a strong, long-handled catch forceps seize the pedicle 
near its attachment, and by traction on and rotation of it, the attach- 
ment is broken up. But little force is required, and little bleeding 
need be feared, unless too strong traction has been exerted. Should 
hemorrhage appear, it is best to cauterize the bleeding surface, if acces- 
sible, with the thermo-cautery. If the pedicle is broad and the polypus 
vascular, incise the base with scissors and cauterize the cut surfaces 
with the thermo-cautery. 

When the polypus is large, distending the vagina and obscuring 
a view of the pedicle, the point of attachment and the size of the 
pedicle should if possible be determined. This can usually be effected 
by a digital exploration, or, if the polypus is too large to permit this, 
a bent uterine sound can usually be carried round and above the 
polypus, when, by manipulation, the attachment can be felt and its 
size estimated. The loop of the wire ecraseur may be carried around 
the tumour and the whole instrument gently carried upward toward 
the cervix. If a strand of piano wire is used, there is usually little 
difficulty in encircling the pedicle. By leaving one end of the wire 
unfastened until the pedicle is reached, it may then be drawn tight 
and the unfastened end of the wire wrapped around the post of the 
ecraseur, when a few turns of the screw will sever the pedicle. 

Sometimes the polypus will be so large that difficulty is experi- 
enced in delivering it. Two courses are then open — namely, section 
of the tumour and its delivery piecemeal, or the application of an 
obstetrical or a specially designed forceps with which to make 
traction. 

When the attachment of the pedicle is above the internal os and 
the tumour presents at the external os or protrudes into the vagina, 
the polypus may frequently be seized with a forceps or tenaculum, 
traction made upon it, and the pedicle cut with scissors. No fear 
of hemorrhage or recurrence of the polypus need be entertained. If 
the polypus is wholly within the internal os, it is probable that the 
tumour is large or the pedicle short. To accomplish its removal, the 
cervical canal should be dilated by the steel dilator, or the cervix may 
be incised and subsequently dilated by the finger or steel dilator. None 
of these procedures is objectionable if conducted under antiseptic pre- 
cautions. With the cervix dilated, the anterior lip may be seized 
with a double tenaculum, the uterus drawn down, and the interior 
of the uterus explored with the ringer. 

In this way small polypi may be located and scraped off with a 



NEOPLASMS OF THE UTERUS 



425 



sharp curette or cut off with long blunt scissors. It has been Dun- 
ning's practice for many years when the pedicle could be distinctly 
located and safely reached by blunt-pointed scissors to sever it with 
scissors in all cases of uterine polypi attached above the internal os. 
Should the tumour be very vascular and contain a large artery, a 
safe and feasible plan is to seize the pedicle in the bite of a long- 
curved pressure forceps and sever it between the forceps and the tumour. 
The forceps should be allowed to remain attached to the stump of the 
pedicle for two days. A large polypus with a short, thick, pedicle 
attached high up can be best extirpated by severing the pedicle with 
a wire ecraseur. 

In all cases of intrauterine polypi, after the removal of one polypus 
the cavity of the uterus should be explored, for occasionally more than 
one growth is present. Should hemorrhage follow the extirpation of 
the polypus from this region, the intrauterine douche of hot water will 
usually arrest it. Vinegar, in proportion of 1 to 3 or 1 to 2 is a valuable 
addition to the douche. If these plans fail, the uterine cavity should 
be packed with plain sterilized or chemically asepticized gauze. The 
operators may choose between the Sims and dorsal positions. Dun- 
ning and many other operators prefer the latter, with the limbs in 
the holders and the cervix exposed by a short, broad, Sims's or Jones's 
speculum. The removal of malignant polypoid growths has not been 
considered in the foregoing remarks. They are best treated b}^ total 
extirpation of the uterus. (See Malignant Neoplasms of the Uterus 
and Vaginal Hysterectomy.) 



CHAPTEE XXIX 

NEOPLASMS OF THE UTERUS (Continued) 

Malignant neoplasms: (a) Syncytioma malignum; (&) adenoma; (c) sarcoma; (d) 
carcinoma — Treatment: (a) Palliative: topical medication, curettement, high 
amputation ; (&) radical : vaginal hysterectomy ; abdomino-vaginal panhyster- 
ectomy; the extended operation; electro-hysterectomy — Results. 

Malignant Neoplasms of the Utektjs 

These will be considered in the following order: (a) syncytioma 
malignum, (b) adenoma uteri, (c) sarcoma uteri, (d) carcinoma uteri, 
(e) exceptional forms. 

These growths, while differing in their histogenesis and in their 
histologic properties, have in common the clinical feature of malig- 
nancy; they are, therefore, neoplasms which, if left to themselves, will 
kill the patient by progressive invasion of tissue and by local and con- 
stitutional conditions that are thereby established. These changes will 
be described in detail in connection with the different diseases. It is 
desirable, in this preliminary paragraph, to emphasize the statement 
that the treatment of malignant neoplasms, to be curative, must involve 
the complete eradication of the growth. In view of the inherent ten- 
dency of these growths to invade the neighbouring tissues, some slowly, 
others rapidly, the operation should, manifestly, be undertaken as soon 
as the malignant character of the growth is determined. So long as 
the neoplasm remains within operable limits, nothing short of its com- 
plete extirpation should be contemplated or attempted. When, how- 
ever, it has passed the operable limit, and has invaded structures and 
organs that can not be dealt with surgically without an immediate fatal 
issue, the patient should be subjected to palliative treatment. The 
rule formerly entertained and adopted, that mild measures should be 
employed in incipient cases and radical measures only in advanced 
cases, should in the interest of humanity be absolutely reversed. 

Syncytioma malignum, known also as deciduoma malignum, malig- 
nant placentoma, carcinoma syncitiale, sarcoma deciduo-chorio-cellulare, 
deciduo-sarcoma, cJiorio-epithelioma, is a degenerative malignant disease 
of the sarcomatous type, originating in the decidual structures of the 
pregnant woman, and tending to a rapidly fatal issue (Fig. 180). 

Maier published in Virchow's Archives for 1875 two observations on 
tumours of the body of the uterus; the tissue composing the tumours 
426 



NEOPLASMS OF THE UTERUS 



427 




was distinctly decidual in character. Hegar subsequently reported 
the death of one of these patients from what he considered to be 
cancer of the uterus. Sanger, in 1888, was the first to demonstrate 
this disease, and, in 1893, to draw attention to its essential histoge- 
netic character and to its pronounced malignant tendency. A number 
of cases have since been reported in various countries, and special 
studies of the disease have 
been made by Whitridge 
Williams in America {Amer- 
ican Journal of Gynecology 
and Obstetrics, June, 1895), 
and Roger Williams in Eng- 
land. Maurice Cazin (La 
Gynecologie, February, 1896) 
made a careful study of the 
disease and did much to 
elucidate its pathology. The 
literature of the subject has 
already grown voluminous. 

Pathology. — These tu- 
mours of the uterus when 
first observed gave rise to a 
great deal of confusion as to 
their true nature and histo- 
genetic classification. There 
are not yet a great many 

cases of this kind on record, because our attention has only recently 
been drawn to them. Syncytioma is found in the uterus after delivery 
at full term, abortion, or mole pregnancy. It forms soft tumours, bleed- 
ing easily, variable in size, generally roundish and small, very malig- 
nant, and with a tendency to form early distant metastases. The sub- 
ject of these tumours has been treated in our country in articles by 
Bacon, Williams, and Gaylord. These neoplasms are derived from the 
chorion epithelium of the placenta and they are therefore of foetal 
origin. On account of this fact they form one of the most peculiar 
malignant neoplasms met with. We have here a tumour spreading in 
the mother, which has taken its origin from foetal structures. There 
are of course quite a number of writers who assert that the syncytium of 
the placenta is of maternal origin. Herzog, from his own work on the 
histology of the placenta and from the recent contributions of Van 
Heukelom, His, Peters, and others, is convinced that the syncytium is 
derived from the foetal ectoderm, and he therefore classifies syncytioma 
malignum under epiblastic epithelial neoplasms. 

Histology. — The tissue of these tumours shows protoplasmic masses 
in which are seen many nuclei, without, however, any cell boundaries 
being recognisable. These masses very much resemble syncytial buds 
(Fig. 181). There are also found cells having the character of those 



Fig. 180. — " Syncytioma malignum ... is a de- 
generative malignant disease of the sarcomatous 
type." — Herzog (page 426). 



428 



A TEXT-BOOK OP GYNECOLOGY 




Fig. 181. — " These masses very much 
resemble syncytial buds." — Heezog 
(page 427). 



of the Langhan's layer of the normal placental villi. Between the 
tracts of tumour cells are large open spaces filled with blood, and 
resembling more or less in character the intervillous spaces of the 

placenta. The syncytioma malignum, 
in other words, represents to a certain 
extent an atypical imitation of normal 
placental tissue. There are sometimes 
present whole chorionic villi, but all 
the tumour cells and structures always 
deviate from the normal placental type 
by marked anaplastic features. 

The causes of this disease are ob- 
scure. It is a suggestive fact, however, 
that of the 15 cases tabulated by Mar- 
chand, 12 gave clear histories of previ- 
ous "mole" j)regnancy. Macnaughton 
Jones states that hydatidiform mole 
has been observed in 45 per cent of the 
cases. The conclusion is, therefore, 
forced upon us that this form of intrauterine infection predisposes to 
the disease, which conclusion may further prove suggestive in regard 
to the general bacterial or parasitic origin of malignant diseases. Be- 
yond this suggestive fact, the etiology of malignant degeneration of the 
decidual structures is shrouded in as deep a mystery as that of other 
malignant diseases. 

The symptoms of syncytioma malignum can not be said to be pa- 
thognomonic. The most significant symptom is severe, intermittent 
hemorrhage, following labour or abortion. This may occur imme- 
diately after the uterus has been emptied; or it may be delayed for 
some time, in which case its onset will be attended by the discharge 
of an hydatid mole. After the hemorrhage ceases, a foul-smelling 
dirty-coloured watery discharge generally ensues. Pain may or may 
not be present; but when it does exist, it is frequently provoked by 
efforts of the uterus to expel clots. The patient is generally cachectic, 
loses flesh rapidly, and speedily shows signs of advanced anaemia. 
Exploration of the pelvis will reveal a uterus more or less enlarged, 
even beyond what might be expected under ordinary circumstances at 
the same period following delivery. The cervix is generally found 
open, although this is far from a constant condition. Digital explora- 
tion of the uterine cavity will reveal coagula beneath which are found 
soft vegetating masses. Cazin calls attention to the fact that the 
neoplastic products are frequently of such consistence that they may 
easily be mistaken for clots. The enlarged uterine wall is cedematous 
and nonresistant, and may, therefore, be perforated with facility in 
the course of examination. 

The diagnosis of syncytioma must depend, so far as the clinical 
features of the case are concerned, largely upon the history of 



NEOPLASMS OF THE UTERUS 429 

pregnancy followed by parturition at term or by abortion; or, par- 
ticularly, the history of hydatid mole. Due attention should be given 
to the symptomatology just recorded; the exact character of the genera- 
tive process, however, can be determined only by microscopic examina- 
tion of some of the tissue. This may be easily removed in some cases 
by the finger, in others by the curette. Another diagnostic sign of 
importance in cases of longer standing is the occurrence of metastases. 
These migrations, in consequence of the special tendency of this dis- 
ease to invade the blood vessels, are manifested at an earlier stage than 
in other malignant diseases of the uterus. 

The treatment must consist of nothing short of the complete removal 
of the uterus and adnexa. (See Vaginal Hysterectomy.) This should 
be done as quickly as the diagnosis can be made. It should be remem- 
bered, however, that metastases occur very early in the history of these 
cases, and that, if their existence is detected, the operation offers the 
patient no hope and is, therefore, unjustifiable. Eoger Williams tabu- 
lated 14 cases of this disease that had been treated by vaginal hysterec- 
tomy: of these. 12 recovered from the operation, while 2 died; of the 
12 primary recoveries, 5 died with recurrence within the first year; 
6 of the remaining 1 were free from recurrence ten. nine, seven, seven, 
five and one half, and three months, respectively, after the operation; 
nothing was said of the after-condition of the other patient. 

Adenoma uteri, otherwise designated adenoma malignum, or ade- 
noma malignum carcinomatosum uteri, is a malignant degeneration of 
the endometrium possessing individual characteristics but having a 
tendency to assume the carcinomatous type. 

To Matthews Duncan probably belongs the distinction of first 
having directed attention to this disease, although at the time of his 
first report its histogenetic character was not recognised. Breisky 
and Eppinger reported undoubted cases in IS??, at which date the real 
literature of the subject commences. Veit was the first to demonstrate 
that what appeared primarily to be simple, benignant adenoma, might 
become a veritable adeno-carcinoma possessing all the characters of 
malignancy. In America. Thomas and Goodell were among the first 
to report cases of apparent malignant adenoma, while Mann was among 
the first to give a clear elucidation of the disease. Coe's contributions 
to the subject have been of great value. 

This neoplasm is looked upon by Herzog as probably not different 
from a carcinoma of a more common type, although it shows such 
characteristic histologic features that it is now generally classified 
separately. Glandular hypertrophy of the uterine mucous membrane 
may reach a very high degree, so that one might feel inclined to speak 
of it as an adenoma: and it has been asserted that such extensive 
glandular hypertrophies have a tendency to change into an adenoma 
malignum. Yet this assertion so far lacks proof. Typical adenoma 
malignum of the uterus, as shown in Oliver's case (Fig. 182), does not, 
as a rule, present a well-circumscribed tumour, but a general diffuse 



430 



A TEXT-BOOK OF GYNECOLOGY 



thickening of the mucous membrane which has an irregular, juicy, 
velvety appearance. The uterus is generally moderately enlarged in 
all its dimensions. In very high degrees of glandular hypertrophy, we 
find the uterine glands often quite tortuous, divided twofold or threefold 

and invaginated upon 
themselves. In adenoma 
malignum the picture 
becomes still more com- 
plicated. The rapid pro- 
liferation of the glan- 
dular epithelium leads 
to one of two conditions. 
Either the newly formed 
epithelia grow toward 
the lumen of the gland, 
and in their growth 
carry inward toward the 
glandular axis the base- 
ment membrane, ade- 
noma malignum inver- 
tens (Fig. 183); or they 
grow outward, away 
from the axis, and then 
an adenoma malignum 
everlens is formed. Of 
course these two types 
may be more or less com- 
bined. It is not easy to 
form a clear conception 
of the microscopic pic- 
ture of these tumours 
even from a very minute 
description. Gebhard 
(Pathologische Anatomie 
der WeiUiche Sexualor- 
gane, 1899), describing 
them in detail, states that nobody, even after studying a full description, 
should imagine himself able to distinguish every adenoma malignum 
from a glandular hypertrophy. Only a good deal of microscopical ex- 
perience can give safety in this respect. Herzog, who has examined sev- 
eral cases of adenoma malignum, saw one among them operated on by 
Henrotin which showed a very interesting histologic combination. The 
uterine mucosa showed the typical picture of an adenoma malignum, 
except in those parts where the tumour had extended into the cervix. 
Here were found regular solid alveolar cell nests, and it appeared that 
the epithelia were squamous in character. Herzog believes that there 
existed primarily an adenoma malignum of the corporeal mucosa. The 




Fig. 182. — u Typical adenoma malignum of the uterus 
as shown in Oliver's case." — Herzog (page 429). 



NEOPLASMS OF THE UTERUS 



431 




malignant process secondarily infected the cervical mucosa where it 
localized itself in squamous epithelia present there, either by a process 
of metaplasia or by one of substitution. 

The symptoms of adenoma uteri are not clearly defined, none of 
them being characteristic of the disease. The first fact of importance 
is the relative chronicity, adenoma being the least active of the various 
malignant degenerations of 
the uterus. The patient will, 
therefore, give a history cov- 
ering a longer period of time 
than would be the case if she 
were afflicted with carci- 
noma. Coe maintains that 
there is less pain, that the 
hemorrhages are less fre- 
quent and less profuse, and 
that the intervening watery 
discharges are less offensive, 
than in carcinoma. The dis- 
ease is not prone to metasta- 
tic manifestations, which oc- 
cur late, if at all. They were 
entirely absent in four of 
Coe's cases. The diagnosis 
depends upon the symptoma- 
tology above indicated, and 
upon the detection of papillomatous growths in the interior of the 
uterus. If uterine scrapings are examined by the microscope the result 
is likely to be negative, which would not be true if the disease were car- 
cinomatous. Adenoma is an insidious disease that runs a slow course of 
invincible malignancy. It is important that the relative good health 
sustained through a long period by patients with this disease, should 
not be construed as an evidence of even a tendency to recovery. The 
profuse hemorrhages, the intervening discharges, the pain and tender- 
ness, may disappear for a time, only to return a little later with added 
violence. 

The treatment, to be on the side of safety, should be arranged with- 
out reference to any remaining pathological question relative to the ex- 
istence, respectively, of benign and malignant adenomata, and should be 
based upon the axiom of Coe, viz.: " There is only one variety of true 
adenoma of the corpus uteri, and that is, both clinically and anatom- 
ically, malignant/' In no other way can a patient be given the benefit 
of the doubt, at least, until the pathologists themselves can distinguish 
between the two alleged varieties, and can furnish to the practitioner 
the criteria by which he can tell the one from the other. Eepeated 
curetting is conceded to augment the malignancy of the disease, while 
the use of the galvano-cautery is equally objectionable. Complete eX- 



FiGL 183.— "The newly formed epithelia grow to- 
ward the lumen of the gland, and in their growth 
carry inward the basement membrane. 11 — Her- 
zog (page 430). 



432 



A TEXT-BOOK OF GYNECOLOGY 



tirpation of the uterus is the only means that offers safety to the patient. 
(See Vaginal Hysterectomy.) The tendency to recurrence after opera- 
tion is less in this than in other malignant diseases of the uterus. 

Sarcoma uteri is a malignant neoplasm having its origin in the 
connective tissue of the uterus, and is characterized by an atypical pro- 
liferation of connective-tissue cells in a fibrous stroma. It occurs 
less frequently than carcinoma of the uterus. The first case was de- 
scribed by Mayer in I860, the diagnosis being confirmed by a micro- 
scopic examination of the specimen by Virchow, but nine cases were 
recorded during the next eleven years. Since that time, however, 
much attention has been given to the subject, and the condition has a 
definite place in pathology and surgical therapeutics. 

Sarcoma of the uterus is not a disease of relatively frequent occur- 
rence. Fran que reports only 16 sarcomata to 304 carcinomata of the 
uterus out of 3,366 cases seen during ten years at the Wiirzburg gyne- 
cological clinic. 

It occurs as a rule in middle and later life, but there have also 
been reported some cases in very young children. (See Causes.) It may 

develop primarily in the mucous 
membrane or in the muscular coat. 
Its seat may be the vaginal portion 
of the cervix, the cervix proper, or 
the body. The latter is more fre- 
quently the seat of sarcoma than 
the other parts of the womb. Sar- 
coma of the mucous membrane 
forms flat, irregular, roundish, or 
polyplike masses. In some cases 
the malignant new growth may 
spring from a small circumscribed 
spot and form a growth which 
macroscopically can not be distin- 
guished from an ordinary polypoid 
hypertrophy of the mucous mem- 
brane. It is of practical impor- 
tance to keep this in mind, because 
there are several examples on rec- 
ord where such harmless-looking 
polyps were removed, a micro- 
scopic examination not being 
made. Shortly after removal, quite 
unexpectedly, a rapidly growing 
malignant sarcoma made its ap- 
pearance. Microscopic examination of such polyps will, of course, 
reveal their nature. Sarcomata of the uterine mucous membrane are as 
a rule quite soft in consistence and have a tendency to spread rapidly. 
They may develop in the uterine cavity and even become pedunculated, 




Fig. 184.—" They may develop in the uter 
ine cavity and even become peduncu 
lated, as shown in a case of Reed's."- 
Herzog (page 433). 



NEOPLASMS OF THE UTERUS 



433 



as shown in a case of Reed's of which George E. Jones made a sketch 
(Fig. 184). They then infiltrate the muscularis diffusely, and, when at 
the same time superficial sloughing takes place, as it frequently does, 
one is not able to ascertain definitely whence the malignant neoplasm 
originally started. A peculiar form of sarcoma of the mucosa is one 
sometimes found arising from the cervix. These sarcomata are of a 
papuliferous type, and, since the papillae are lrypertrophic, the whole 
growth looks very much like a hydatid mole. Primar}^ sarcoma of the 
uterine wall generally begins as multiple nodules or roundish masses. 
It likewise usually rapidly infiltrates the muscularis and the mucosa 
and soon leads to destructive processes in the latter. These malignant 
connective-tissue tumours, when growing in the uterus, frequently have 
the tendency to close the os internum in a valvelike manner. This leads 
to one - of the constant objective symptoms of sarcoma of the uterus, 
namely, periodical discharges of an accumulated bloody-watery fluid. 
Sarcoma of the uterus spreads by continuity and not infrequently leads 
to a marked enlargement of the uterus in all its dimensions. There 
may, however, also occur a thinning of the uterine wall with inversion. 
Such a case has been reported by E. Williams. Distant metastases 
sometimes take place. Secondary sarcomatous degeneration of prima- 
rily benign myomata has been mentioned above. 

The histology of sarcoma uteri is that of these malignant connective- 
tissue tumours in general. The neoplasm may be composed of small 
or laro-e round cells, spindle 



and 



giant 



cells, 

tumour cells as a 

their 

titia of blood 

they proliferate 

an infiltratino- manner. 



origin from the 



cells. The 

rule take 

adven- 

vessels, and 

diffusely in 

A 



regular 



structure, 




alveolai 

like that of carcinoma, is 
rarely found. The sarcoma- 
tous tissue is very rich in 
blood vessels and free hemor- 
rhages are found. It is some- 
times difficult to distinguish 
a beginning sarcoma of the 
mucous membrane from a 
profound endometritis inter- 
stitialis. The expert, how- 
ever, will be able to make a 
diagnosis from the finer cyto- 
logic characteristics of the neoplasm. In sarcoma of the uterus, the 
tumour cells show marked variation in size and shape and they present 
atypical karyokineses. such as multipolar figures, hyperchromatoses, 
nuclear 



Fig. 185.— ''In sarcoma of the uterus the tumour 
cells show marked variation in size and shape, 
and they present atypical karyokineses." — 
Herzog. 



fragmentation, 
29 



etc. (Fig. 185). Herzog (Transactions of the 



434 



A TEXT-BOOK OF GYNECOLOGY 



Chicago Pathological Society, vol. iii, 1899) has described a sarcoma of 
the uterus showing a number of interesting histologic features; among 
them numerous atypical karyokineses and the presence of a large 
number of phagocytic cells. These, which are not to be confounded 
with leucocytes, are large tissue cells in the interior of which lympho- 
cytes, leucocytes, and red blood corpuscles, intact or in various stages 
of dissolution, are found. 

Secondary degenerations in sarcoma of the uterus are usually 
marked and appear quite early. Hemorrhage is one of the most con- 




Fig. 186. — " . . . The tumour, which was distinctly sarcomatous, was retroperitoneal, occu- 
pied the whole pelvis, and lifted the uterus quite to the umbilicus." — Reed (page 435). 



stant occurrences and it leads to the destruction of the neoplastic tissue. 
Besides such apoplectic destruction we find fatty, hyaline, and colloid 
degeneration. 

Our knowledge of endothelioma of the uterus is still very meagre. 
Cases have been reported by Amann, Braetz, Gebhard, Grape, McFar- 
land, Pick, and Veit. These malignant tumours, in their macroscopic 



NEOPLASMS OF THE UTERUS 



435 



characters, are similar either to the sarcomata or to the carcinomata. 
The cases reported occurred in women between the ages of eighteen 
and fifty-two years. The endotheliomata take their origin from vascu- 
lar or lymphatic endothelial cells, and are more or less alveolar in 
structure. 

The researches of Kleinschmidt and Kahlden indicate that sarco- 
mata may arise from the connective-tissue elements of the blood vessels 
and lymphatics in the parenchyma of the uterus; while Virchow, Eo- 
kitansky, and Schroder, recognise that fibromyomata may undergo 
sarcomatous degeneration. (See Fibromyomata.) There is abundant 
evidence, however, that sarcomata, originating in the parenchyma and 
abounding in round and spindle celled elements, may possess sufficient 
fibrous stroma to give 
them a consistence by 
which they may be 
mistaken for fibro- 
mata. The so-called 
" recurrent fibroids " 
belong to this class. 
Some of them grow 
to enormous size. A 
case reported by Ott 
(Annales de gynecolo- 
gie et d'obstetrique) 
which had been op- 
erated upon by Le- 
bederT, three years 
previously, and was 
followed by appar- 
ent cure, developed 
a retroperitoneal tu- 
mour which lifted the 
uterus nearly to the 
umbilicus. Eeed op- 
erated upon a similar 
case (Fig. 186) in the 
Cincinnati Hospital 
(1900); the tumour, 
which was distinct- 
ly sarcomatous, was 
retroperitoneal, occu- 
pied the whole pelvis, and lifted the uterus quite to the umbilicus. 
After the removal of the tumour with the uterus, the latter seemed 
relatively small as it was seen perched upon the mass (Fig. 187). 

The symptoms of sarcoma of the uterus are hemorrhage, offen- 
sive discharge, and pain, differing in no essential particular from the 
symptoms of carcinoma. Pain does not occur as a rule in the earlier 




Fig. 187.— "After the removal of the tumour with the uterus, 
the latter seemed relatively small as it was seen perched 
upon the mass." — Reed. 



436 A TEXT-BOOK OF GYNECOLOGY 

stages of the disease, but is very constant in the later stages. The 
uterus is generally enlarged and if kept under observation will be 
found to increase more rapidly than in true carcinoma. If the cervix 
is dilated to a degree sufficient to permit of digitation of the cavity, the 
neoplasm, if originating from the connective tissue of the endometrium, 
and if of the distinctly round-celled variety, will be soft and friable. In 
the majority of cases, it will be impossible to distinguish sarcoma from 
carcinoma, without a microscopic examination. The more solid sar- 
comata of parenchymatous origin have about the same morphology as 
fibroids, from which they are distinguishable, as a rule, only by their 
more rapid growth; and even this point may be misleading when a 
tumour of the strictly myomatous type, in consequence of pressure, 
becomes suddenly oedematous. In view of the fact that rapidly-growing 
solid tumours of the uterus are sometimes distinctly sarcomatous from 
the start, and, in view of the fact that those which are myomatous in 
the beginning may undergo sarcomatous degeneration, it is safer to 
look upon all of them as essentially malignant. 

The causes of sarcoma of the uterus are not determined. The fact 
that it is a disease of the extremes of life, and especially of old age, 
would indicate that age is a possible factor. It is difficult to reconcile 
the evidence on this point. Thus Roger Williams finds that instances 
have been reported by Farnsworth at thirteen months, by Pick at two 
years, by Ahlfeld at three years and four months; and at various ages 
by Hereford, Clay, and Pick. Of 73 cases, by Gusserow, 4 began under 
the age of twenty-nine; 5 began from twenty to thirty; 15 began from 
thirty to forty; 28 began from forty to fifty; 18 began from fifty to 
sixty; 3 began above sixty. Pregnancy and the marital relation do not 
seem to exercise much influence. Of Gusserow's 73 cases, 35 were pa- 
rous women, who, between them, had borne fifty-one children; 25 
of his cases were absolutely sterile, 4 of them being virgins. There 
is no evidence that even in parous women the traumatism of parturition 
bears any relation to this disease. 

The treatment of sarcoma, like that of other malignant diseases of 
the uterus, must consist of such means as will secure its complete eradi- 
cation. This can be accomplished only by the extirpation of the uterus. 
(See Vaginal Hysterectomy.) The disease is one of the most malig- 
nant and should, therefore, be attacked as soon as detected. An at- 
tempt has been made to treat sarcoma of the uterus, as of the more 
superficial structures, with the toxines of erysipelas and the Bacillus 
prodigiosus. Coley, who is largely responsible for the introduction of 
the treatment, calls attention to the fact that collapse is liable to occur 
from too large a dose, especially when injected into a very vascular 
tumour, and that pyaemia has resulted from the use of the serum. The 
toxines, to be of value, must be prepared from highly virulent cultures 
of the streptococcus of erysipelas. They seem to act upon sarcoma by 
inducing a rapidly progressing necrobiosis with fatty degeneration, to 
secure which the toxines are to be injected directly into the tumour. 



NEOPLASMS OF THE UTERUS 437 

This treatment should never be employed in a case amenable to opera- 
tion, while in one not amenable, any treatment which seems to rest upon 
a logical basis is justifiable. Franque reports that in 16 cases of sar- 
coma occurring at the Wurzburg clinic, 1 case remained cured for five 
years after three operations. Another case was free from recurrence 
after two years and 4 remained well for one year. Two died on the 
table after operation. These results are more satisfactory than those 
reported by Rogivue, in 50 cases treated by hysterectomy. Of these 
but 3 remained cured, 32 were known to have had a return of the 
disease, 2 of them within a year after the operation. 

Carcinoma uteri is a malignant growth, consisting of epithelial cells 
embedded in a stroma of embryonal character, and of either congenital 
or post-natal origin. It is an affection which was known to Hippoc- 
rates and other ancient medical writers. The uterus is probably the 
most common seat of carcinoma in the human body, although older 
statistics give the stomach the first place. However, when these statis- 
tics were compiled, some affections of the uterus really carcinomatous in 
nature, such as the so-called papillomata and cauliflower excrescences, 
were not counted in their proper places. According to the statistics of 
the Registrar General, there died in England from cancer between 1847 
and 1861, 87,348 persons. Of these, 25,633 were males and 61,715 
females. About 25,000 of the latter succumbed to cancer of the uterus. 
It is now asserted that carcinoma in general, and carcinoma of the 
uterus in particular, is frightfully on the increase. Park has recently 
attempted to show the correctness of this assertion so far as one sec- 
tion of our country is concerned. Duhrssen (Die Verhuetung des 
Gebarmutterkrebses, Medici nisclie Woche, 1899), in commenting upon 
the horrible increase of cancer of the uterus, states that 25,000 die 
annually in the German Empire from carcinoma uteri, or three times 
as many as die in childbed from all causes. This author thinks that 
only from 10 to 30 per cent of all cases in Germany are still amen- 
able to operation when a definite diagnosis is first made, because it is, 
as a rule, made too late. He therefore recommends that women be 
made acquainted, through popular writings of medical men, with the 
dangers of carcinoma of the womb; further, that every means should be 
tried in every single case to arrive at a correct diagnosis early. After 
this is made, everything possible should be done to induce the patient 
to submit to an immediate operation. Winter (Lehrbuch der Gyna- 
hologischen Diagnostic, Leipzig, 1897, p. 216) upon this subject says: 
" The diagnosis of carcinoma of the uterus is the most responsible the 
physician is called upon to make. The price for every failure of diag- 
nosis, or for a diagnosis made so late that the cancer has already become 
unsuited for operation, is a human life. Under all circumstances, and 
with all means at our disposal, we must strive to diagnose cancer at 
the very first examination. To wait in a suspicious case until destruc- 
tive properties become manifest, as was so frequently done formerly, is 
to-day a most serious mistake." 



438 A TEXT-BOOK OF GYNECOLOGY 

The above quotations are here cited to impress the student and 
practitioner with the importance of the earliest possible diagnosis of 
carcinoma of the uterus, in which alone lies the only possible salvation. 
After the very earliest stages, cases have, as a rule, become unsuited to 
operation and are beyond human aid. 

Cancer of the womb is rare before the age of thirty, more common 
between the fortieth and sixtieth years. It drops again after sixty years, 
but not so much on account of its real infrequency at that period, as 
on account of the smaller number of females alive after that age. 
Married life and childbirth have an obvious influence upon the liability 
to carcinoma. An hereditary predisposition is likewise manifest. 

Pathology. — Carcinoma of the uterus may take its origin from 
the portio vaginalis, the cervix proper, or the body of the uterus. 
Carcinoma of the portio vaginalis is variable in its macroscopic charac- 
ters, and a good deal in this respect depends upon the rapidity and 
the intensity of secondary, retrograde, destructive processes. The cauli- 
flower excrescences, or polypoid carcinomata of the portio, arise from the 
lips, and form either broad bases or somewhat constricted pedunculated 
tumour masses, varying in size from a hazelnut to an apple. The sur- 
face of these neoplasms is never smooth, but uneven with crevices and 
clefts. It may be pale and whitish or of a pinkish tint, but the colour 
of the tumour itself is generally hidden from view by a dirty, sero- 
purulent, bloody, greenish or yellowish, secretion. In another form 
of carcinoma of this part of the uterus, we find a diffuse infiltration 
and hardening of the portio. In early stages, ulcerations may be en- 
tirely absent and the surface may be smooth. When this form begins 
to ulcerate there may be present shallow ulcers only, while in the forms 
first described, the ulcerations usually lead to great destruction of the 
tissue and form craterlike cavities. In spreading, carcinoma of the por- 
tio vaginalis generally first reaches and then infiltrates the vaginal walls. 
Early spreading into the cervical mucous membrane is rare. Involve- 
ment of the corpus uteri in primary carcinoma of the portio is quite 
rare. In their further growth these cancers infiltrate the lateral para- 
metrium. The bladder is, as a rule, reached only late, and then from the 
anterior vault of the vagina. Involvement of the rectum is rare. The 
lymphatics involved are those following the course of the iliac vessels. 

Carcinoma of the cervix takes its origin from the surface or from 
the glandular epithelium of this part. It usually begins as a cir- 
cumscribed nodule or as a diffuse infiltration, involving either part 
or the whole of the circumference of the cervix. A very marked infil- 
tration formed in this manner may then ulcerate and lead to extensive 
loss of substance and excavation. Or, there may be from the start a 
slight degree of infiltration only, with early shallow ulcerations and 
destruction of the superficial layers. Spreading goes on from the 
cervix in the direction of the body. It may have the form of a super- 
ficial ulceration along the corporeal mucous membrane, or it may be 
a diffuse or circumscribed lymphatic infiltration into the uterine wall. 



NEOPLASMS OF THE UTERUS 439 

Spreading over the vaginal mucous membrane rarely, if ever, occurs, 
but later on, an infiltration of the deeper layers of the vaginal vails is 
common. The pelvic connective tissue is generally invaded from the 
deepest part of the growth. The bladder is often involved early, the 
rectum, as a rule, late. Lymph-gland involvement is similar to that 
in carcinoma of the portio. 

Carcinoma of the body of the uterus starts from the corporeal mucous 
membrane. In the diffuse form the whole mucous membrane is more 
or less involved and, in places, infiltrated with thicker roundish or 
irregular nodules. The further development of the new growth en- 
larges the corpus uteri in all its dimensions and the cavity becomes 
markedly enlarged so soon as ulcerative processes and sloughing set in. 
Sometimes there may be only a circumscribed limited carcinomatous 
process, while the major part of the mucous membrane is not involved. 
The polypoid form of carcinoma of the body is rare. When carcinoma 
of the corpus in its extension reaches the outer zone of the body, ad- 
hesions to surrounding parts become frequent, particularly to the intes- 
tines, which may become perforated by carcinomatous growth. In- 
volvement of the bladder and the rectum occurs late, as a rule. The 
lymph glands generally first involved are the lumbar glands in the 
neighbourhood of the aorta. There may be in all forms of carcinoma 
of any part of the uterus, an unusual involvement of lymph glands in 
consequence of reversed metastatic transport. 

Histology. — Carcinoma of the uterus is a malignant atypical neo- 
plasm arising from epithelial structures and showing, as a rule, the 
well-marked alveolar arrangement so characteristic of cancer. Since 
we find two different kinds of epithelia in the uterus we also find car- 
cinomata differing in the types of their cells. The cancers spring- 
ing from the portio are almost invariably squamous-celled carcinomata. 
The epithelia lining the portio proliferate rapidly, and infiltrate the 
underlying connective tissue in the form of pegs or columns or pillars 
of cells. These cells in proliferating vary a good deal in shape, and 
deviate from the type from which they originally sprang. In the 
cervix where we normally have no squamous, but only cylindrical 
cells, we likewise find besides columnar-celled cancers, squamous 
epithelial carcinomata. This is probably not so much due as some 
believe to a preceding or coinciding metaplasia of the epithelia, as to a 
preceding substitution by which the columnar epithelium has been 
replaced by that of a squamous type (Fig. 188). Carcinoma of the cor- 
pus consists, as a rule, of epithelia of the columnar type. But it must 
be kept in mind, that as soon as we have a well-developed alveolar 
arrangement in the neoplasm, the epithelia have become so atypical 
in shape and size that one can speak with propriety, neither of colum- 
nar nor of squamous cells; the latter under these considerations also 
lose their prickles. 

It is very difficult to distinguish between glandular hypertrophy 
and beginning carcinoma. Eecourse must be had to atypical mitotic 



440 



A TEXT-BOOK OF GYNECOLOGY 



figures which always speak strongly for tumour formation. These 
features have been more fully mentioned above under the head of Sar- 
coma Uteri. Amann (Mikroskopische Gyndhologische Diagnose, Wies- 
baden, 1897) attaches a good deal of significance to the direction of the 
polar spindle with reference to the surface on which the epithelia are 

situated, in the matter of 
diagnosis between simple hy- 
pertrophy or malignant neo- 
plasm. It is impossible here 
to go into the finer details of 
the microscopic diagnosis of 
carcinoma. In a well-devel- 
oped case, when it is, how- 
ever, usually too late to op- 
erate, the histologic picture 
is so typical that even a tyro 
can make a microscopic diag- 
nosis. While, on the other 
hand, in the very beginning, 
when there is still time for 
a hopeful operation, it often 
requires delicate fixation, ex- 
act orientation, and general 
careful preparation of the 
microscopical material, to 
enable even the expert to arrive at a definite conclusion. In trying to 
get at the latter it is perhaps better, as stated by Herzog in a paper on 
The Microscopic Diagnosis of Uterine Scrapings, to err on the side of 
too great a readiness to see atypical and malignant features, instead of 
being too ready and prone to overlook the former and to see only hyper- 
plastic processes; particularly, since the suspected cases, as a rule, with 
few exceptions, occur in women at a period when the uterus has ac- 
complished its object as a fruit bearer, and when its removal is not 
objectionable from physiological and social reasons. 

The causes of carcinoma of the uterus are by no means determined. 
The disease is liable to occur at any age. Pozzi mentions a case by 
Ganghoffer, of a child nine years old, who died from medullary carci- 
noma. Gusserow accumulated the records of 3,385 cases showing the 
age at which carcinomatous diseases began, as follows : 




Fig. 188. — " The columnar epithelium has been 
replaced by that of a squamous type." — Herzog 
439). 



17 years 1 case (Glatter). 

19 years 1 " (Beigel). 

20 to 30 years. . . 114 cases. 
30 to 40 years... 770 " 



40 to 50 years 1,196 cases. 

50 to 60 years 856 " 

60 to 70 years 340 " 

Above 70 years 193 " 



Pozzi maintains that poverty is a predisposing cause of carcinoma, 
and supports his contention by the statistics of Schroder, showing that 
the disease is 1.5 per cent more frequent in the charity wards of the 



NEOPLASMS OF THE UTERUS 441 

hospitals than in private practice. These statistics are sustained by 
the observations of A. Martin. Duhrssen, on the other hand, quotes 
Koger Williams approvingly to the effect that uterine cancer is not, 
as was believed, more frequent in the lower classes, but that predis- 
position to this disease is given by the over-feeding and comfortable 
position of those in better circumstances. Duhrssen further asserts 
that more women die annually in. Germany from carcinoma than there 
were soldiers killed in the entire Franco-Prussian War, the mortality 
ranging from 0.5 to 1.0 per thousand; and that all classes alike are 
susceptible to the disease. The traumatisms of parturition have been 
looked upon as causes of carcinoma of the uterus; while the frequent 
observation of commencing cancer at the site of an old laceration, and 
the well-known tendency of cicatricial tissue to undergo malignant 
degeneration, have been quoted in support of the theory. Statistical 
tables bearing upon this point are valueless, in view of the fact that 
the majority of women are married and have children, and of the 
additional fact that individual cases are constantly occurring in unmar- 
ried and continent women. 

The question of the parasitic origin of carcinoma of the uterus in- 
volves the question of the germ origin of carcinomata in general. 
Edmund Andrews has conducted a series of investigations touching 
this point from which he concludes that, other things being equal, 
primary carcinoma is most frequent on those surfaces which, by their 
position, would be most accessible to free swimming microbes or spores 
derived from without the body; that the liability to cancer is increased 
if the epithelial surface is so situated that the spores can remain upon 
it for at least some hours without being washed away; and that the 
liability to cancer is great if the membrane has vast numbers of deep 
glandular follicles into which the spores can penetrate, and lie free 
from disturbance, and gain direct access to the more delicate epithelial 
cells. He has made an interesting computation showing the liability 
of different surfaces to carcinoma in proportion to their exposure to 
germs and their ability to afford to them an undisturbed lodging, by 
which he arrives at the conclusion that the cervix uteri is 5,776 times 
more liable to cancerous disease, than is a similar area of intestine, 
which he computes at unity and uses as a standard for comparison. It 
is interesting to note that the vagina is as 61 to 1 and the vulva as 264 to 
1 in the same scale. A number of culture and inoculation experiments 
have been made with reference to demonstrating the bacterial origin 
of carcinoma. Francke (Miincliener medicinische Wochenschrift) be- 
lieved that he had confirmed the alleged discovery by Scheurlen of a 
bacillus of carcinoma. This bacillus was described as being 2 micro- 
millimetres long and 0.4 micromillimetres broad, and as producing 
in culture media a reddish-brown pigment. Subsequent investigation, 
however, failed to substantiate the claims of this bacillus to recognition 
as the essential organism of carcinoma. While this organism has not 
been isolated, evidence points in the direction of a bacterial origin of 



442 A TEXT-BOOK OF GYNECOLOGY 

this disease. Hanan (Fortschritte der Medizin) transferred small por- 
tions of the secondary growth in the inguinal and axillary glands of a 
white rat, dead from carcinoma of the vulva, to the abdominal cavities 
of two other rats; one of these animals died at the end of two months, 
and there were found in its omentum fully developed nodules rich in 
the cellular elements of carcinoma; while in the other animal there 
were evidences of a successful vaccination of carcinoma. The repetition 
of these and similar experiments, especially by Italian investigators, has 
confirmed the inoculability of carcinoma, although the precise ele- 
ment upon which this inoculability depends has not yet been deter- 
mined. The most that can be concluded at present is, that the evi- 
dence points in the direction of the bacterial origin of carcinoma. The 
investigations now in progress under the supervision of Roswell Park 
bid fair to result in more definite conclusions. 

The symptoms of carcinoma of the uterus are uncertain and indefi- 
nite in the earlier stages, the disease in the majority of instances being 
exceedingly insidious in its onset. Pain is rarely present until after 
the disease has made considerable progress. When it is located in 
the cervix, the first symptom to arrest the attention of the patient will 
be a persistent watery discharge slightly tinged with blood; this may 
or may not be associated with fcetor. A little later, the discharge be- 
comes distinctly sanguineous, and, as the disease progresses, irregular 
and violent hemorrhages occur. The uterus by this time generally 
becomes more or less painful — particularly if the endometrium is in- 
volved, or if there is an upward extension of the disease from the cervix. 
The occurrence of hemorrhage at the menopause, or following it, 
should be regarded with suspicion, and should always be the occasion 
for a careful local exploration. The diagnosis is generally obvious in 
cases of carcinoma involving the cervix. The finger will at once detect 
an enlargement of that segment of the womb; if in the earlier stages, 
the tissues will seem nodular and indurated; if in the later stages, after 
disintegration sets in, the surface will be irregularly granular and 
friable, bleeding upon the slightest touch. At this stage, to the experi- 
enced surgeon, the odour of the discharges is so characteristic that a 
diagnosis is made, as a rule, before the examination is begun. In cases 
of carcinoma involving the corpus uteri, diagnosis will be based, first, 
upon their rarity, and, next, upon the microscopic examination of some 
of the tissue removed. In all cases of suspected cancer of the uterus, 
when the disease is not so advanced that the diagnosis practically de- 
clares itself, a microscopic examination should be made of a piece of 
tissue removed from the diseased area. This is especially true when 
the disease is in its incipiency, manifesting itself by either an indurated 
nodule or a circumscribed erosion of the cervix. It is not important, 
from a practical point of view, to distinguish between carcinoma and 
sarcoma of the uterus, as the treatment is precisely the same in either 
case. As a matter of scientific interest, however, the investigations of 
Adamkiewicz (CentraMatt fur die medicinischen Wisse7ischaften, Berlin) 



NEOPLASMS OF THE UTERUS 



US 



are worthy of attention. He has endeavoured to establish distinctions 
between carcinoma and sarcoma by inoculation experiments. If fresh 
carcinoma tissue is implanted in the brain of an animal — preferably a 
rabbit — the animal will die in the course of two or three days, with 
severe lesions only to be explained by migration of the elements of the 
implanted carcinoma tissue into the interstices of the brain substance, 
and subsequent production of patches of inflammation and necrosis. 
Carcinoma tissue also responds with a typical reaction to " cancroin," 
the trimethylvinylammoniumoxydhydrate base of neurine, the specific 
poison which kills the carcinoma coccidium. Adamkiewicz therefore 
suggests as an infallible means of distinguishing carcinoma to implant 
a scrap of the suspected tissue in a rabbit's brain. If it is not carci- 
noma, the tissue will be absorbed and the animal will remain in its usual 
health. This and the absence of the cancroin reaction indicate a non- 
carcinomatous character for the neoplasm. 

There are many complications of cancer of the uterus. Carci- 
noma may occur in a myomatous uterus; while myomata themselves 
are liable to undergo malignant degeneration — especially of the sar- 
comatous type. The coexist- 
ence of various benign and ma- 
lignant neoplasms in the same 
uterus, while not frequent, is 
occasionally encountered. The 
coexistence of sarcoma, carci- 
noma, myoma, and polypus, is 
reported by Xeibergal (Archiv 
fur Gynakologie, 1896) (Fig. 
189). In cases in which car- 
cinoma or other malignant 
neoplasms have begun to dis- 
integrate, mixed infections of 
the endometrium speedily 
ensue. 

Pregnancy as a complica- 
tion of carcinoma of the uterus 
is occasionally encountered. 
It is always a serious compli- 
cation, and one that is a men- 
ace alike to the life of the 
foetus and of the mother. An 
interesting series of one hun- 
dred and sixty-six cases of 
cancer of the uterus, occur- 
ring between 1886 and 1895, has been compiled by George H. Noble, 
of Atlanta, Ga. The complication is one which precludes the pos- 
sibility of normal delivery, even should pregnancy go to term, while 
abortion is likely to prove fatal. Reed has reported (Transactions of 




Fig 



189. — " The coexistence of sarcoma, carci- 
noma, myoma, and polypus is reported by 
Neibero-al." — Reed. 



444 A TEXT-BOOK OF GYNECOLOGY 

the Ohio State Medical Society) a case in which amputation of the cervix 
for carcinoma had been done by another operator in the presence of 
unsuspected pregnancy, and in which the patient was permitted to go 
to term; when labour began, the cervix was found to be distinctly car- 
cinomatous — a condition which, in the absence of necessary surgical aid, 
speedily resulted in the death of both mother and child. When the 
cancerous uterus is found to be impregnated, vaginal hysterectomy 
should be done in the earlier stages of the pregnancy; or, if the woman 
is permitted to go to term, she should be delivered by Csesarean sec- 
tion or the Porro operation. Vaginal hysterectomy should be em- 
ployed so long as there is a reasonable opportunity of delivering the 
diseased and impregnated organ by that route; the Porro operation 
(abdominal hysterectomy) should be done in the later stages of preg- 
nancy, when there is a prospect of removing all of the malignant struc- 
tures; the conservative Cesarean operation, according to Noble, 
" ought to be employed in all cases with obstruction to the birth of the 
child by extensive exudate, or where there is not a reasonable hope of 
eradicating malignancy." The question of operative interference 
after the period of viability has been reached, is one which can not be 
settled by any definite criteria. The condition ought to be explained 
to the family and especially to the patient, who should be given an 
opportunity to choose between the desperate alternatives. The fact 
should be remembered, that a carcinomatous uterus may be able to 
carry a pregnancy to term, and that a living child may be born by 
either the Csesarean or the Porro operations. At the same time, it 
should be clearly held in mind that, in consequence of a pregnancy, a 
carcinomatous uterus may be suddenly provoked to violent and fatal 
hemorrhage. The time for operation, and the character of the opera- 
tion, should be determined by the surgeon and the patient in full 
recognition of these facts. 

The prognosis of carcinoma if left to itself is that of inevitable fatal- 
ity. The average duration of life when the disease follows a natural 
course is from twelve to eighteen months. In cases in which disease 
is too advanced for radical operation, the conservative treatment by 
curettement stops hemorrhage and waste, and prolongs life, but, of 
course, only defers for a time the inevitable termination. 

Treatment: Palliative. — Topical Medication. — A quarter of a cen- 
tury ago, when the microscope was not in extensive use, cases of 
ulceration of the cervix, one centimetre or more in diameter, were 
encountered, which were looked upon as ulcers, chancres, or begin- 
ning cancers. It was the custom to treat such cases with lunar 
caustic, nitric acid, etc., making an application once in four or five 
days. Carstens has observed cases in which this treatment has been 
followed by perfect healing, though the disease was certainly not 
syphilitic. Hence the condition must have been benign or the be- 
ginning of a malignant growth. On the contrary, in some cases 
thus treated the patients were apparently cured but died a year or 



NEOPLASMS OF THE UTERUS 445 

two later of cancer. It may be possible that those patients that re- 
covered permanently had a nonmalignant nicer; while those who 
developed cancer in a year or two had ulcers that were cancerous 
in the first place, but, by the application of caustic, the removal of 
the neoplastic formation, and the stimulation of healthy granulation, 
the parts healed, although in the deeper structures cancer cells re- 
mained, which continued to develop and involve the whole womb and 
the surrounding structures. In more advanced cases the cervix was 
removed and then cauterized with chromic acid, pure bromine, mercuric 
nitrate, zinc chloride, etc. The various pastes and plasters used even 
to-day by quacks who call themselves cancer doctors, have long been 
discarded. The basis of all these plasters and pastes has been either 
arsenic, lime, or zinc. Any of these preparations placed in quantity 
on soft tissues will destroy them in various directions and in a most 
irregular manner that can not be controlled. 

It was left to J. Marion Sims to put the nonsurgical treatment on 
a scientific basis, and his method has been followed with very slight 
modifications ever since by gynecologists. To-day, with all our sur- 
gical experience, we meet with many lamentable cases which are beyond 
our surgical skill. All we can do is to relieve symptoms, stop the 
hemorrhages, prevent the drain on the system, ease the pain, and 
prolong life. When the uterus is fixed or the broad ligament involved, 
perhaps even the base of the bladder or the vagina, a vaginal hyster- 
ectomy is of no use. In such cases Carstens proceeds as follows: All 
diseased tissues are thoroughly removed with the knife, scissors, or 
sharp curette, going over the ground repeatedly, so that the appar- 
ently healthy tissues are reached. When working at the base of the 
bladder or rectum, great caution must be exercised to prevent per- 
foration. The hemorrhage may be extensive at first, but as more 
healthy tissues are reached, the hemorrhage ceases unless the circular 
or uterine arteries, which may require the application of a ligature 
or the forceps, are opened. 

Sims's method was to apply iron perchloride to this large raw sur- 
face to stop the hemorrhage, removing it in twenty-four hours, and 
then applying caustic; but, as caustic is the best hemostatic, Car- 
stens always applies it at once as follows: A piece of absorbent cotton, 
of a size and shape to suit the cavity and made round or long accord- 
ing to indications, is attached to a string. This is clipped in a solution 
of zinc chloride, one ounce, to half an ounce of water. It is then 
squeezed as dry as possible, care being taken to dry the fingers imme- 
diately, to prevent damage to them, or, still better, to conduct the 
whole operation with rubber gloves. Having again dried the cavity, 
the cotton is carefully placed so that it comes thoroughly in contact 
with all the raw surface. If it is not dry enough, it will run down 
the vagina and cause trouble there. To prevent this accident, Sims 
suggested filling the vagina with absorbent cotton and saturating it 
with sodium bicarbonate which would immediately neutralize the zinc; 



446 A TEXT-BOOK OF GYNECOLOGY 

but this method is improved upon by Carstens, who takes a ball of dry 
absorbent cotton large enough to fill the vagina, and to which also a 
string is attached, and packs it into the vagina. The upper part catches 
any little discharge of the chloride of zinc, minimizing its caustic 
action and limiting it to the upper part of the vagina. In the string 
attached to the cotton containing the chloride of zinc, one knot is 
tied. In that attached to the dry cotton two knots are tied, in 
order to distinguish them and to indicate in which order to remove 
them. This packing is allowed to remain for forty-eight hours, when 
it is removed and vaginal douches used. The slough that is formed 
by the caustic comes away in about ten days, often in one large piece, 
leaving beneath it a clean granulating surface, which rapidly contracts, 
and frequently entirely closes, except the small fistulous opening 
through which menstruation can take place. It is astonishing how 
quickly women will recover and gain strength after this procedure; 
the discharge ceases, the appetite improves, and the patient gains in 
weight twenty or thirty pounds in three months. In the course of 
time, however, recurrence takes place, sometimes within six months, 
sometimes not for a year or more. If the case is carefully watched, the 
foregoing procedure can be repeated at once on recurrence, and, if 
taken very early, the small point where recurrence takes place can be 
easily curetted and cauterized without the use of an anaesthetic. Sec- 
ondary deposits in the pelvic lymphatics or those of the intestines or 
stomach are, of course, beyond reach. 

Bromine is so volatile and difficult to handle that it affords no 
advantages whatever, and Carstens has entirely discarded it. Formalin 
has been recommended. Calcium carbide was recommended by the 
late J. H. Etheridge, of Chicago, but its use in the hands of others 
yields no more benefit than, if as much as, is derived from the zinc 
chloride. The technique of the use of these various caustics is the 
same as that previously given for the zinc chloride. It seems that 
the latter remedy is the best that can be used in such lamentable cases. 

The treatment of malignant growths by serum is still in its in- 
fancy. The consensus of the profession seems to be, that in cancer 
it is of no benefit, but that in cases of sarcoma, a limited number 
seem to be benefited. Carstens has tried it in quite a number of 
cases with absolutely no benefit, and it has been used in the hospital 
under his observation in many cases, for malignant growths of dif- 
ferent kinds and situated in different parts of the body, without 
benefit. It has seemed to him that in some cases there is a spontaneous 
cure of sarcoma. He is sure that he has seen a number of cases in 
which a disease that had been pronounced sarcoma by various physi- 
cians, has entirely disappeared. But our knowledge is still so limited 
that little hope of benefit from serum therapy can be entertained. If 
the future discovers the microbe of cancer, as may be hoped, we may 
hope also that an antitoxine will be produced which will check the 
ravages of this terrible disease. 



NEOPLASMS OF THE UTERUS 447 

Curettement, considered as a palliative measure in advanced cases, 
is an expedient in favour with many operators. With the patient 
under an anaesthetic, the diseased parts niay he scraped thoroughly 
with a Eecamier or other sharp curette, with the Simon scoop, or with 
the Thomas spoon-saw. The scraping should be followed by daily 
vaginal injections with antiseptic solutions. Carstens never practises 
this method, on the ground that, if he did, he might as well practise 
cauterization (see ante), which he insists will accomplish more gcod. 

High amputation of the cervix is indicated in cases in which the 
disease has gone beyond the uterus, and where the discharge is so dis- 
agreeable, and the hemorrhage so extensive, as to make life a burden. 
With the brilliant results of to-day, achieved by the complete removal 
of the uterus, so-called " high amputation " is practised but rarely, 
and should never be employed when the organ is removable. The 
patient, under the influence of an anaesthetic, is placed on her back 
with her buttocks on the edge of the operating table. After the vagina 
has been thoroughly cleansed, a retractor is inserted. The diseased 
parts are grasped with volsella forceps and the cauliflower growth re- 
moved with scissors, after which the vagina is again cleansed. Then, 
with a two- or three-pronged volsella forceps, the cervix is seized more 
firmly, an incision is made all round the uterus at the junction of the 
mucous membrane of the vagina and of the cervix; the vaginal mucous 
membrane is next pushed back with the fingers, or with a blunt dissec- 
tor, for a quarter of an inch or so, and a conical piece removed from the 
uterus. The apex of this cone corresponds to the uterine canal. The 
hemorrhage is quite profuse when the circular artery is cut, and will 
require ligation of the vessel. Sometimes a simple twisting of the 
artery will be sufficient, but this measure is not trustworthy. The 
cavity thus produced can be packed with antiseptic gauze, but it is 
better to treat it with zinc chloride as before mentioned. 

The radical treatment of carcinoma of the uterus consists in the 
extirpation of the diseased organ, and of the neighbouring lymphatic 
glands when they are involved and removable. The operation has 
been extended in recent years to include the removal of lymphatic 
glands from the interior of the pelvis, and to the removal of a part or 
all of the vagina. The uterus may be removed by either the vaginal 
route (vaginal hysterectomy), or by abdominal section (abdomino- 
vaginal panliysterectomy). 

Vaginal Hysterectomy. — The removal of the uterus by the vaginal 
route is not a new operation, having been performed in a limited num- 
ber of cases early in the present century by several operators, among 
whom Osiander, von Langenbeck, and Sauter were prominent. But 
the technique then practised met with such indifferent success that the 
procedure was practically abandoned until the advent of antiseptic sur- 
gery and improved hemostasis. Its revival is due to the work of Czerny 
in 1878, since which time it has by many operators been given the pref- 
erence in selected cases over the abdominal route. 



448 



A TEXT-BOOK OF GYNECOLOGY 



Instruments for Vaginal Hysterectomy 



Catheter, glass 1 

Curette, small (Sims's modified) 1 

Martin's 1 

Forceps, long dissecting (Fig. 190) .... 1 

Short dissecting 2 

Long hemostatic 6 



Packer, vaginal (Fig. 193) 1 

Retractors, large 1 pair. 

Next size smaller 1 " 

Small size. 1 •' 

Scalpels 2 

Scissors, long 1 pair. 

Sharp-pointed 1 " 

Speculum, Jones's 1 



Sims's medium 

Simon's, with handles and four 

blades 

Sound, uterine 

Sponge holders (Fig. 194) 

Tenaculum. Cullen's (Fig. 195) . . 

Straight 

Blunt 

Round, sharp 



Medium hemostatic 6 

Small hemostatic 6 

Bullet 2 

Needles, curved (Fig. 191), large 2 

Small 2 

Medium 2 

Transfixion, right curved 1 

Straight 1 

Needle holders (Fig. 192) 2 

Museux's volsella forceps 2 

Hysterectomy forceps, Pean's curved . 2 

Pean's straight 2 

An angeiotribe or a Skene's electro-hemostatic forceps (see Hemo- 
stasis), with attachments, should be at hand provided the operator de- 
sires to avail himself of these means of hemostasis. 

Technique of Vaginal Hysterectomy. — The procedure is as follows: 
The patient, prepared as is usual for vaginal and peritoneal section, is 
placed in the lithotomy position with the hips well over the edge of 
the table. The posterior vaginal wall is retracted by means of a Sims 

or Alvard, or preferably 
a Jones, self -retaining 
speculum, exposing the 
vaginal vault and cervix 
, uteri. The anterior lip 
of the cervix is seized 
with the volsella forceps, 
and the uterus drawn 
down (Fig. 196), continu- 
ous irrigation with a 
solution of bichloride 
(1 to 4,000) being em- 
ployed from this point 
until the peritoneal cav- 
ity is opened. 

Fig. 190.— Dissecting forceps.— Kobe. In septic, and some 

cancerous cases, the cer- 
vical canal should be curetted and swabbed with a 95-per-cent solution of 
carbolic acid. When extensive sloughing of the cervix has occurred, it is 
best to curette and cauterize it during the preparatory treatment of the 
preceding week, to eliminate as much debris and septic material as pos- 
sible from the field of operation. In all cases, curetting and cauteriza- 




NEOPLASMS OF THE UTERUS 



U9 



tion is followed by sewing together of the anterior and posterior lips of 
the os, effectually closing it against leakage from the affected organ. 
This is accomplished by three or fonr interrupted sutures of the strong- 
est braided silk, the ends of which are left long for traction. A circular 
incision is made through 
the mucous membrane of 
the vagina, and carried 
round the entire cervix, 
keeping close to that or- 
gan except in carcinoma- 
tous cases where a margin 
of 2 centimetres (0.75 
inch) should be allowed 
for possible cellular inva- 
sion. The electric cautery 
or the thermo-cautery is 
substituted for the knife 
or scissors by some oper- 
ators in making this dis- 
section, to obviate the use 
of catgut or silk ligatures 
not infrequently required 
on the vaginal arteries. 

Newman uses the in- 
dex and middle fingers to 
peel up the layer of con- 
nective tissue from in 
front of, and behind, the 
cervix until the perito- 
neum is reached. This can be recognised by the smooth gliding of 
its surfaces one upon another, and the small fluid accumulations in 
the cul-de-sac of Douglas. The irrigation of the vagina is now dis- 
continued, and sponging with gauze substituted. The peritoneum is 
seized with tissue or artery forceps, nicked with the scissors, and 
the finger thrust through into the peritoneal cavity. The opening 
is extended witli the ringers, as far as the broad ligament upon either 
side. The outer surfaces of the uterus, its adnexa and surrounding 
structures, are carefully examined, adhesions broken up, and a gauze 
sponge with tape attached, to which a catch forceps is applied, should 
be carried up into the peritoneal cavity to protect the parts from 
infectious material, and prevent the protrusion of omentum and in- 
testine. 

In the separation of the bladder from the anterior cervical attach- 
ments, great care should be exercised not to perforate or injure this 
organ or the ureters situated at the sides and front of the wound in its 
lower portion. Accident may be avoided by keeping the palmar sur- 
face of the dissecting fingers in close apposition to the uterine walls. 
30 




Fig. 191. — Curved needles. — Robb i page 4-iS 



450 



A TEXT-BOOK OF GYNECOLOGY 



The vesico-iiterine folds of the peritoneal membrane are opened 
close to their uterine attachment and the fingers inserted, enlarging the 
opening laterally, pushing the ureters carefully to either side, and com- 
pleting the separation of the bladder. The uterus will now be found 
suspended in the pelvis by the broad and round ligaments alone. The 
clamping or ligating of this vascular area should be done with great care 
and precision, and, in each instance before the application of the clamp 
or ligature, its site should be drawn down and carefully inspected. 

With the cervix drawn well to the left, and using lateral retractors 
to bring the structures well into view, the base of the right broad liga- 
ment is seized between the left thumb in 
front and index finger behind, and the 
uterine artery palpated. The portion of the 
ligament containing the artery is now in- 
cluded in the bite of a strong ligament 





Fig. 192.— Needle 
holders. — Eobb 

(page 448). 



Fig. 193.— Pack- 
er. — Eobb (page 
448). 



Fig. 195.— Cullen's 
tenaculum. — Eobb 
(page 448). 



Fig. 194. — Sponge holders. 
—Eobb (page 448). 



forceps, or a strong silk ligature is applied about a centimetre distant 
from the uterus with a full curved aneurism needle (Fig. 197), and 
tied firmly. 

The structures are now divided with scissors between the clamp or 
ligature and the uterus, close to that organ; and the base of the left 
broad ligament, with the uterine artery of that side, is treated in the 
same way. 



NEOPLASMS OF THE UTERUS 



451 



Firm traction brings down the uterus for the placing of a second 
clamp or ligature immediately above the first on either side, and the 
tissues are incised in the same manner. 

Using the finger as a guide, a large blunt hook or the finger is now 
passed over the top of the broad ligament, one side brought down suffi- 
ciently to permit the ap- 
plication of a third clamp 
or ligature, and the last 
incision is made, freeing 
the uterus entirely from 
its attachments upon that 
side. The fundus is 
drawn down outside the 
vulva, the clamp or liga- 
ture easily applied to the 
remaining portion of the 
broad ligament, and the 
uterus cut away. 

Many operators vary 
this technique at the 
point where the uterine 
arteries have been se- 
cured by clamp or for- 
ceps, and the base of the 
broad ligament incised, 
b}^ rotating the uterus 
forward through the an- 
terior vesico-uterine in- 
cision, or backward 
through the posterior 
cul-de-sac. As a rule, 
this is easily accom- 
plished by first pushing 
the cervix upward and 
forward, or backward, as 
the case may be, and then 

seizing the body of the uterus a little in advance of the cervix with 
a strong volsella forceps, and drawing it down either anteriorly or pos- 
teriorly, as desired. A second forceps then secures the tissues a little 
higher up, rotating or dragging the fundus still farther downward until 
it can be grasped and drawn out completely inverted. 

The ligation or clamping of the ovarian arteries or the upper por- 
tion of the broad ligament, now proceeds from above downward, close to 
the uterus if the ovaries are to be saved, or beyond both tubes and ova- 
ries along the tubo-infundibular ligament, if they are to be sacrificed. 

Careful inspection should now be made of the stumps of the broad 
ligament, which are gently drawn down for the purpose. If there is 




Fig. 196. — " The anterior lip of the cervix is seized with 
the volsella forceps and the uterus drawn down.*' — 
Newman (page 448). 



452 



A TEXT-BOOK OF GYNECOLOGY 



~> 



any bleeding, the insecure clamp or ligature should be readjusted. 
The vagina is sponged free of clots, and the sponge or sponges removed 
from the peritoneal cavity. A running catgut suture, which should 
include peritoneal and vaginal tissue, closes the vaginal vault, and 
secures the stumps of the broad ligaments in either 
angle of the wound. 

Full-width gauze, or narrower, with edges 
hemmed to prevent fraying, is used to pack the 
vaginal vault. 

Where the forceps is used and suturing of the 
vault omitted, particular care should be taken to pro- 
tect the ends of the clamps from projecting upward 
and coming in contact with the intestines. In this 
case the gauze packing not only protects the ends 
of the forceps and serves for drainage, but, being 
carefully placed above between the stumps of the 
broad ligament, prevents hernia or protrusion of the 
intestines. Gauze should also be so placed about the 
shanks of the forceps as to prevent danger of tissue 
necrosis of the vagina or vulva. The usual vulvar 
dressings are now applied, the handles of the forceps 
wrapped with gauze, and the patient put to bed. 
The urine should be drawn every six or eight hours, 
and the external genitals bathed each time with 1-to- 
4,000 bichloride. The forceps are removed in from 
36 to 48 hours, but the gauze packing remains undis- 
turbed for from 24 to 48 hours longer. 

When the gauze is removed at the end of this 
time the patient should be in a good light and the 
packed area in full view, so that there may be no 
danger of disturbing the superimposed intestines. 
A careful douching of the parts with sterilized 
water or boric-acid solution, may now be used twice daily, taking care 
not to carry the douche point too high up, or to allow too great force 
to the flow. The bowels should be moved by a laxative pill or mild 
salines followed by an enema the second day, and each day thereafter. 
No straining at stool should be allowed. Liquid diet should be given 
for three or four days, followed by nourishing but easily digested soft 
foods, nutritious broths, soft-boiled eggs, custards, and the like. 

When the ligatures have been used upon the broad ligaments and 
fail to come away within a reasonable time after the operation, in the 
second or third week they should be gently drawn upon daily, and if 
still resistant, Sims's speculum should be used, and the ligatures 
removed under ocular inspection by cutting the loop. In general, the 
patient may be allowed to sit up in bed at the beginning of the third 
week, and at its end may be up in an easy chair, and about the room in 
the fourth week of convalescence. 



Fig. 197. — "A full 
curved aneurism 
needle." — New- 
man (page 450). 



NEOPLASMS OF THE UTERUS 453 

All cancer cases should be carefully examined from time to time 
for recurrence of the disease. 

Among the later and more important modifications in the tech- 
nique of vaginal hysterectomy, should be mentioned that of removing 
with the cancerous uterus the pelvic lymphatic glands, a procedure 
analogous to the operation upon the axillary glands in mammary carci- 
noma; the operation described and done by Sippel, who opened into 
the ischiorectal cavity by lateral incision between the anus and the 
tuber ischii, and removed the vagina and uterus unopened and in their 
normal connection, claiming as advantages a good view, the accessi- 
bility of field, and the possibility of avoiding any contact whatever 
with carcinoma, or the contents of the vagina; and the use of the 
angeiotribe, or pressure clamp, to replace both retention clamps and 
ligatures for hemostasis of the broad ligament in vaginal and abdominal 
hysterectomy. 

Abdominovaginal panhysterectomy for malignant disease has been 
strongly advocated by some, where the uterus could not be pulled down 
on account of adhesions, and also for the purpose of more thoroughly 
removing diseased tissues and the lymphatic glands situated within the 
broad ligaments, near the crest of the ilium, or in the neighbourhood 
of the ureters. There are exceptional cases in which this operation 
is required. When vaginal hysterectomy by the clamp method was 
in its infancy and only one clamp was used on each broad ligament, 
the tissues would sometimes pull out and the hemorrhage could not be 
stopped, so that the abdomen had to be opened in order to control the 
bleeding. With the present technique, this seldom if ever occurs. 
When the disease is so far advanced that the uterus with the diseased 
tissues can not be removed per vaginam, surgical intervention is of no 
avail for ultimate cure, while the immediate mortality certainly must 
be great. When metastasis into the lymphatics has once taken place 
there is no guarantee that it can be overtaken. The experience of 
distinguished operators goes to show that secondary deposits are more 
liable to occur in the stomach, liver, or high up in the intestines, than 
anywhere else. Hence Carstens would not advocate abdominal section 
in malignant diseases except in cases of sarcoma where the uterus is 
very large and still movable. There are others, however, who assume 
that continued efforts should be made to eradicate, if possible, carci- 
nomatous glands of the pelvis. Although the operation is one of ex- 
treme severity it has a certain justification in the otherwise hopeless 
character of the disease. It ought not to be undertaken without hav- 
ing been first explained to the patient, who ought to be frankly advised 
of the desperate alternatives. It is, to-day, an operation from which 
nothing can be promised — although something may be realized. 

The extended operation for advanced carcinoma of the uterus in- 
volves the removal, not only of the diseased organ, but also of the 
infected lymphatics within the pelvis. The operation is graphically 
described {American Gynecological and Obstetrical Journal, 1898) by 



454 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 198. — " The patient is placed in a very 
steep Trendelenburg position." — Reed. 



Emil Reis. The patient is placed in a very steep Trendelenburg posi- 
tion (Fig. 198) and an incision is made from the pubis to the umbilicus. 
The intestines either sink or are placed back toward the diaphragm, 
after which the surgeon inspects and palpates the pelvic organs and 
the large blood vessels from the aorta to Poupart's ligament and to 
the uterine artery. If during this examination enlarged and im- 
movable glands are found, it is 
advisable to cut the operation 
short and to do only such pallia- 
tive work as will afford as little 
clanger to the patient's life and as 
much protection against hemor- 
rhage, discharge, and pain, as 
possible. If there is no such en- 
largement of the glands, the op- 
eration continues as follows: 
First, the right infundibulo-pel- 
vic ligament is ligated close to 
the pelvic wall; a clamp covers 
the broad ligament between the 
ligature and the uterus, and the 
ligament is cut through between 
the ligature and the clamp. The 
peritoneum is now incised along 
the common iliac vessels, which are further exposed by blunt or 
sharp dissection. Pushing the peritoneum back toward the side, 
the ureter, which crosses the common iliac vessels on or near their 
bifurcation, is soon reached. The ureter is then laid bare from the 
brim of the pelvis down to its point of entrance into the bladder, 
with the aid of an incision through the peritoneum of the vesico- 
uterine pouch. As this is done under the constant guidance of the 
eye there is no danger of injuring the ureter. The blood vessels 
which are cut in this procedure are ligated or temporarily provided for 
with clamps. The uterine artery is plainly seen in this dissection at 
a point where it crosses the ureter, and can easily be ligated under the 
guidance of the eye at its starting-point from the hypogastric artery 
outside the ureter. After the ureter is thus laid bare and the uterine and 
ovarian vessels are secured, there is remarkably little hemorrhage from 
the procedure which follows and forms the most important new step in 
this operation — the removal of the lymphatics with the surrounding fat 
and connective tissue. This is done by dissection with either a blunt or 
a sharp instrument. The area which was cleaned out in this way 
extended in Reis's cases over a surface limited by the lateral edge of 
the external iliac vessels superiorly, the pelvic wall laterally, the blad- 
der anteriorly, the pelvic floor inferiorly, and posteriorly by the meso- 
rectum which, however, was lifted up and freed from all accessible 
glands. Bleeding vessels are ligated, or the hemorrhage, when it comes 



NEOPLASMS OF THE UTERUS 455 

from the side of the uterus, is checked by clamps, or simply by pull- 
ing hard on the uterus. Two edges of the peritoneum remain after 
the whole broad ligament and all the fat and connective tissue along the 
large vessels and the pelvic wall are removed. If adhesions exist between 
uterus and rectum, they are cut as close to the rectum as possible, be- 
cause they sometimes form the path along which carcinoma spreads. 

Then the procedure as done on the right side is repeated on the 
left, special attention being necessary here in order to empty the 
mesorectum as completely as possible without injuring too many of 
the hemorrhoidal vessels. The ureter and uterine artery are treated in 
the same way; the removal of fat and connective tissue with the lym- 
phatics being carried to the same extent as on the other side. The peri- 
toneum is left open for the time being, as on the other side, that the 
hemorrhage may be stopped by ligation of the blood vessels. Small ar- 
teries supplying the lymphatic glands sometimes give rise to some hem- 
orrhage and must be secured by ligatures. The round ligaments are 
severed close to the anterior abdominal wall. The peritoneum of the 
■cul-de-sac is now incised close to the rectum and the vagina is perfo- 
rated at this point, either against the finger of an assistant, or against 
gauze introduced into the vagina. The vagina is severed after its walls 
have been secured by ligatures. The uterus is in this way freed all 
round and is removed. The wound can be closed toward the peritoneal 
•cavity by suturing the peritoneal edges left in removing the broad liga- 
ments and the uterus. This suture runs across the bottom of the pelvis 
in a transverse direction, uniting laterally the edges of the peritoneum 
•of the vesico-uterine and recto-uterine pouches, and in the median 
line the peritoneum of the bladder and the rectum. Before this part 
of the operation, the space between the peritoneum and the cut edges of 
the vagina is filled with iodoform gauze if there is any oozing, or, if 
everything is perfectly dry, the cut edges of the vagina and the peri- 
toneum can be closed in such way as to leave no dead spaces between 
them. The subsequent management of the case is the same as in 
abdominovaginal, section for benign growths. 

Werder, of Pittsburg, has extended the operation of abdominal 
hysterectomy for cancer by removing, in certain cases, all or a part of 
the vagina. The operation is done as in an ordinary hysterectomy, 
only after freeing the bladder the dissection is extended down along 
the vagina, separating its anterior wall from the bladder as far down 
as it is desirable to remove the vagina; the recto-vaginal space is then 
entered and the posterior wall is stripped off the rectum so far as is 
necessary, and, finally, the lateral attachments of the vagina are 
loosened. The uterus is now pushed down into the pelvic outlet, the va- 
gina being inverted by making traction from below until it can be am- 
putated above the prolapsed fundus. Werder claims for this operation 
that it affords the best opportunity for maintaining an aseptic field, 
since it can be done without touching the diseased cervix with the fin- 
gers. He has reported successful results from this method of operating. 



456 



A TEXT-BOOK OP GYNECOLOGY 



Byrne's Operation of Electro-hysterectomy. — An operation that 
has occasioned much confusion in the surgical world is that devised 
by John Byrne, of Brooklyn, and designated by him " high amputa- 
tion of the cervix/' It consists in the removal of the whole uterus ex- 
cept a thin shell at the fundus (Fig. 199) and is, to all intents and pur- 
poses, a hysterectomy, the uterus being cut out by an electric knife, 

"followed by thorough dry 
roasting of the remaining ex- 
cavation." To designate it as 
" high amputation of the cer- 
vix " and to attribute its re- 
sults to " amputation of the 
cervix," is to impart the mis- 
leading idea that those results 
have been realized by the re- 
moval of merely the lower seg- 
ment of the uterus. The title 
mistakenly given to this opera- 
tion has itself, and without any 
reference to the scope of the 
procedure, prompted many not 
overstudious operators to at- 
tempt the cure of cancer of the 
cervix by simple amputation of 
the neck of the uterus. The re- 
sult has been a tragic mortality, 
much of which might have 
been avoided; but which has, happily, resulted in the emphatic verdict 
of the profession that the surgical treatment of cancer of the uterus, to 
be successful, must involve the removal of the entire organ. Of the 
various operations for the removal of the uterus, none are more effect- 
ive, and certainly none are followed by more satisfactory ultimate re- 
sults, than the brilliant procedure of Bryne, as practised by himself, 
and described (Electro-Hemostasis, Skene, p. 71) as follows: 

" A diverging volsella, after being passed well into the cervical 
canal, should be expanded to a proper degree and locked, so as to 
afford complete control of the uterus during the entire operation. 
By alternate traction and upward pressure of the uterus, an accurate 
idea may be obtained as to the proper point to begin the circular in- 
cision, so as to avoid injuring the bladder or opening into the cul-de- 
sac of Douglas. As to the latter, however, should it be found that the 
disease has involved the retro-uterine tissues, and that its excision 
or destruction by the cautery can not be effected without opening into 
the peritoneal cavity, there need be no hesitation in doing so. I have 
never known any harm to come from it whether it was done acciden- 
tally or by design. Should it be evident at the outset that the opera- 
tion, in order to be thorough, must include a portion of the cul-de-sac, 




Fig. 199.—" It consists in the removal of the 
whole uterus except a thin shell at the fun- 
dus." — Keed. 



NEOPLASMS OF THE UTERUS 457 

it will be better to make the line of incision anterior to this, until the 
cervix has been removed, and leave the incision of the retro-uterine 
parts by the cautery knife to be the final proceeding. Under these 
circumstances all that will be needed will be an antiseptic tampon prop- 
erly applied. In proceeding to make the circular incision, the cautery 
knife, slightly curved and cold, should be applied close up to the 
vaginal junction, and from the moment the current is turned on, 
should be kept in contact with the parts being incised. Before remov- 
ing the electrode for any purpose, such as change of position, or alter- 
ing the curve of the knife, the current should first be stopped and the 
instrument again placed into position while cool before resuming the 
incision. In other words, if the knife, though heated only to a dull 
red, be applied to parts at all vascular, hemorrhage more or less 
will certainly follow; whereas, the cool platinum blade being already 
in contact with moisture as the current is being transformed into heat, 
vessels are shrunken or closed even before they are severed. This is a 
very important point and should never be lost sight of in all cautery 
operations. The circular incision having been made to the depth, say, 
of a quarter of an inch, it will now be observed that by increased trac- 
tion the uterus may be drawn much farther downward, and by directing 
the knife upward and inward the amputation may be carried to any 
desired extent. In cases calling for amputation above the os internum, 
it will be better to excise and remove the cervix first; then, by dilat- 
ing the upper canal sufficiently to admit the diverging volsella, once 
more proceed as in the first instance, taking care, however, to keep 
within bounds. It will be found that the cupped stump can now be 
drawn down and made to project as a more or less convex body. In 
all cases the dome-shaped electrode should be passed over the entire 
cavity repeatedly so as to render the cauterization still more complete. 
It is important to add that, in carrying the knife toward the sides of 
the cervix, circular and other arterial branches are likely to be encoun- 
tered, and hence, in this locality particularly, a high degree of heat in 
the platinum blade is to be carefully avoided. As an additional secu- 
rity against hemorrhage, the convexity of the knife should be pressed 
against the external surface of each particular section cut, so as to 
close the vessels more effectually. It is well to state that the metallic 
parts of the electrode for the distance of about two inches should be 
covered with a strip of thin flannel, so that the vagina may be protected 
from injury through the reflected heat/' (See Eesults of Operative 
Treatment of Carcinoma Uteri.) 

Byrne claims for this operation that, by the action of heat on the 
surrounding structures, any possible remaining infection within them 
is destroyed, and that following the operation there is an absence of 
fever, and of almost all pain, either pelvic or peritoneal; that there is 
almost universal immunity of the scar tissue, after cauterization, from 
secondary attack in the event of the recurrence of the disease; and, 
finally, that in the event of relapse, the respite from reappearance of 



458 A TEXT-BOOK OF GYNECOLOGY 

disease in remote parts, even in the more unpromising cases of un- 
doubted circumuterine infiltration, is longer than in other operations. 

The results of hysterectomy for carcinoma should be considered as 
(a) immediate, (b) remote. The immediate results are concerned with 
the surgical recovery of the patient from the operation. The remote 
results take into consideration the permanency of the cure thereby 
secured. One of the most interesting of recent statistical researches 
relative to the immediate results of vaginal hysterectomy has been 
conducted by Ricard, of Paris (La semaine gynecologique, October 31, 
1899), who places the primary mortality of vaginal hysterectomy at 
the hands of French surgeons at from 16 to 19.68 per cent. Monclaire 
and Picque place the mortality in Prance at 8.9 per cent, this computa- 
tion being based upon 2,376 cases. Bigeard concludes, after a careful 
study of both the French and foreign statistics, that the primary mor- 
tality from this operation vacillates between 17 and 20 per cent. This 
is probably the representative figure. Hofmeier in 74 vaginal hyster- 
ectomies reported a mortality of 16.2 per cent. Munchmeier (Frauen- 
arzt) reported 80 vaginal hysterectomies with 4 deaths. Byrne finds 
that in 1,273 colpohysterectomies by 38 European and American sur- 
geons the average primary mortality is 14.6. 

The figures relating to the remote or ultimate results of vaginal 
hysterectomy for cancer, are less satisfactory than those relating to 
primary results, for the sole reason that it is exceedingly difficult to 
keep track of the cases after they once pass from the surgeon's hands. 
The reports on this point from various operators are strangely conflict- 
ing. Thus, Bouilly states that all his cases operated upon since 1886 
are dead; and Jacobs reports the same of his annual series of cases 
running back respectively three, four, five, and six years. On the other 
hand, Thorn, reviewing the statistics of the Magdeburg Clinic, con- 
cludes that half the cases in which the disease is limited to the uterus, 
operated upon in that institution, have a permanent recovery. Riche- 
lot has cases alive six, eight, nine, and twelve years, after operation. 
Freund reported nonrecurrence in a case eleven years after operation 
and Olshausen reported a case of immunity after twelve years. Reed 
has cases of nonrecurrence covering periods of respectively twelve, ten, 
nine, eight, seven, six, five years and less. McMurtry has a case of 
nonrecurrence after twelve years, and other American operators have 
cases of immunity after even longer periods. 

The extended operation for carcinoma of the uterus has been followed 
by results which seem to justify its employment, particularly when it 
is remembered that without it the condition of these patients is abso- 
lutely hopeless. Reis has collected the tables of cases on page 459. 

The primary results are not so satisfactory as in vaginal hysterec- 
tomy, but they may certainly be looked upon as justifiable when the 
otherwise hopeless character of the cases is taken into consideration. 
The adoption of this operation has been so recent that ultimate results 
are not yet determinable. 



NEOPLASMS OF THE UTERUS 459 



Rum pf, Berlin (Centralblatt fur Gynakologie, Aug., 1895) 
Clark, Baltimore {Bulletin of the Johns Hopkins Hos- 
pital, 1896) .' 8 

Kiistner, Breslau (Peiser Zeitschrift fur Geburtshulfe 

1898) ' 

Private communication from Boston , 

Emil Beis 



Total. 



Cases. 


Recoveries. 


Deaths. 


1 


1 




8 


7 


1 




1 
3 


2 

2 


1 

1 


15 


12 

= 80£ 


3 
= 20£ 



The results of electro-hysterectomy as practised by Byrne, can not be 
designated by any other term than brilliant. These results are sum- 
marized by Byrne himself in a paper before the American Gyneco- 
logical Society, 1896, which begins with an allusion to a previous 
report to that body, and is as follows: 

" I stated that in -10 out of 63 cases of cancer of the portio vaginalis 
(23 having strayed away) periods of exemption from relapse were 
obtained ranging from two to twenty-two years, being an average 
of over nine years for each; and of 50 out of 81 cases involving the 
entire cervix (31 being lost sight of), 10 had an exemption from 
recurrence for over two years, 11 over three years, 6 over four 
j r ears, 8 over five years, 6 over seven years, 2 over eleven years, 1 over 
thirteen years, and 1 over seventeen years. Xor is this all, for the 
fable would now bear important reconstruction — no less than 6 of these 
cases, and probably many more, having until now enjoyed a complete 
immunity. Moreover, one patient operated on in 1875, and a most un- 
promising case too, and who could not be found at the time of my 
report, has since been discovered by Dr. Homer L. Bartlet, of Flatbush, 
with whom I saw her, and who was present at the operation. Two 
months ago, or nearly twenty-one years after the operation, she was in 
perfect health/* 



CHAPTEE XXX 

CESAREAN SECTION AND ITS MODIFICATIONS 

Definition and historical resume — Indications — Preparations — Instruments — Posi- 
tion of child and placenta — The operation — After-treatment — Sanger's method 
— Porro's modification. 

CiESABEAN" section is an operation whereby an opening is made 
in the abdominal wall, and another in the uterus, through which the 
foetus is extracted. 

According to Pliny, it is named Cesarean because the first of the 
Caesars was so extracted from his mother's womb as she was dying. 
According to another version it is named from the operation itself, 
" casso matris utero." 

This operation was at first done upon dead women at a more 
or less advanced stage of pregnancy. It is attributed to Xuma Pom- 
pilius, one of the first Kings of Eome, who enacted (lex regia) that a 
pregnant woman, deceased, must not be interred until the foetus was 
extracted. This law remained in operation throughout all countries 
under Roman rule, and was approved by the Church, as well as adopted 
as a civil law by the Northern states of Europe, more especially Ger- 
many. For many years they dared not perform the operation upon a 
living woman, and in this way encouraged the performance of crani- 
otomy, as the passage of the foetus through the pelvis in cases of de- 
formity was impossible without mutilation. 

Levret and Mauriceau deny that this operation was known to the 
ancients, but Dionis and Gardien refer to Pliny's Natural History. 
Mansfield published a work On the Antiquity of Gastrotomy and Hys- 
terotomy on the Living. (Ueber das Alter des Bauch und Gebarmut- 
terschnitts an Lebenden. Braunschweig, 1824.) He states that even 
in an earlier work than Pliny's, named Mischnajoth, written about 
140 B.C., there is this passage: "In a twin birth, neither the first 
child which by section of the belly is brought into the world, nor 
the one coming after, can attain the rights of heirship or priestly 
office." 

Mcolai Falconiis recorded a case at Venice in 1491. The case of 
Jacob Mefer, the Swiss peasant who performed it upon his own wife, 
is frequently quoted, but most authorities are agreed that it was much 
later before it was generally attempted upon the living woman. In 
fact, we need only refer to the action of Mauriceau in the case treated 
460 



CESAREAN SECTION AND ITS MODIFICATIONS 461 

by himself and Chainberlin, where the operation was delayed until 
after death, although Alauriceau was in actual attendance for several 
days. He wrote: "The child had been dead to all appearance about 
four days, and I told all the assistants that she could not be delivered. 
They asked me to perform Cesarean section, which I did not wish to 
do, knowing that it was always certain death to the mother." This 
poor woman died with her infant in utero, twenty-four hours after- 
ward. 

Eousset, physician to Catherine de' Medici, and contemporary of 
Pare, published a work upon the subject in 1581. This book was 
translated into Latin about ten years later. The author attempted 
to prove the possibility of saving the mother and child by means of 
this operation, but his views were opposed by Pare, Guillemeau and 
others. In the middle of last century, the subject divided operators 
into two sections, the Symphysiens and Ccesariens, or those who advo- 
cated division of the symphysis pubis and those who advocated Cesar- 
ean section. 

It may be taken as a recognised rule in midwifery that no woman 
should be allowed to die undelivered without some attempt being made 
to save her and her offspring, or, at least to save her, even at the 
expense of her child. 

Concerning the latter point, whether we are justified in destroying 
the infant when alive, there has been, and still exists, difference of 
opinion, due in some measure to religious belief, and likewise to the 
personal feeling of the husband, who often felt that very little hope 
was held out to him that his wife could be saved by section. Among 
such men we had Xapoleon, who, when appealed to by Dubois, said: 
" Treat the Empress as you would a shopkeeper's wife in the Eue St. 
Martin, but, if one life must be lost, by all means save the mother." In 
marked contrast to him we had Henry YIII, who. when thus ques- 
tioned before the birth of his son Edward, exclaimed: " Save the child 
by all means, for other wives can be easily found." At the present 
time such men might be put down as either a good husband but a 
bad father, or a good father but a bad husband. 

The doctrine of the Eoman Catholic Church has been that, even 
though it would be impossible to extract the child without first killing 
it, to do so would be mortal sin; and likewise, until lately, it was held 
that the infant could not be baptized in the uterus, as it must be 
nat us before it could be re n at us by baptism. 

Of late years, the happy results following Cesarean section and 
Porro's operation have done much to efface the dreadful feeling, that 
we have in such cases to decide whether the life of the mother or 
that of the child is to have our preference, seeing that it is now quite 
possible to save both. 

Barnes wrote: "Cesarean section is resorted to with a feeling 
akin to despair. Embryotomy stands first, and must be adopted in 
every case where it can be carried out without injuring the mother. 



462 A TEXT-BOOK OF GYNECOLOGY 

Cesarean section comes last, and must be resorted to in those cases 
where embryotomy is either impracticable, or can not be carried out 
without injuring the mother. There is therefore no election. The 
law is defined and clear. Cesarean section is the last refuge of stern 
necessity." 

As against this statement, Barnes has recently said: " It is no 
longer permitted to us, without ample proof of clear necessity, to 
sacrifice the child in order to save the mother. The cases in which the 
two lives are supposed to stand in antagonism are vanishing before the 
light of modern science and skill/' 

If anything is needed to sicken one at the revolting practice of 
craniotomy, it might surely be found in the relation of the obstetrical 
history of a rhachitic woman, who during her last three confinements 
was under the care of Murdoch Cameron: 

1st 1862 Embryotomy. 

2d 1863 Embryotomy (labour induced). 

3d 1864 Embryotomy. 

4th 1865 Induced labour at half term. 

5th Embryotomy (Birmingham Lying-in Hospital). 

6th 1868 Induced labour at half term. 

7th 1870 Embryotomy. 

8th 1871 Embryotomy (eighth month). 

9th 1873 Embryotomy. 

10th 1874 Embryotomy. 

11th 1875 Induced labour at half term. 

We must never forget that we have a sacred trust, and Cameron 
holds that we have no right to sacrifice a child, however unequal its 
life may be in some cases to that of the mother. In advocating the 
preference for section as against craniotomy in the living child, Came- 
ron does so only after very mature consideration, and with a feeling 
that to do otherwise would be to sacrifice a life which we are bound 
to preserve. He thinks the time has come when the lives of the 
mother and child may alike be saved, and prefers to think that an 
infant come to maturity is destined for something greater than to have 
its glimmering life extinguished by an accoucheur skilled in the use of 
a dreadful perforator. Let our motto be, " We live to save and not 
to destroy." 

In another case where the obstetrical history was like the preceding 
one, Cesarean section was performed, and the mother has now attained 
her long-wished-for desire, a living child. 

Burns in 24 cases gave 22 deaths, while others gave the death 
rate as from 50 to 100 per cent. 

With such results it is not to be wondered at that so many opposed 
the operation. In England, for example, accoucheurs condemned it 
absolutely. In Paris, during half a century, there was not a success- 
ful case, although it had been performed about 60 times. In the large 
maternity hospitals of Paris and Vienna, with from 4,000 to 8,000 



CESAREAN SECTION AND ITS MODIFICATIONS 



463 



confinements in the year, not a single successful case of Cesarean 
section has been recorded. Xo doubt now exists that the great fatality 
was due to the fact that the operation was only resorted to after other 
measures had failed. 

Indications for the Operation. — As regards the general indications 
for the operation, of course they vary in the hands of different opera- 
tors, since some, still looking upon Cesarean section as a last resource, 
divide the indications into absolute and relative. The absolute indica- 
tion exists where the deformity of the pelvis is so pronounced that 
the passage of even a mutilated foetus is impossible; while the relative, 
is where a mutilated foetus may be removed by the natural passage 
with as good a result for the mother as, or even better than, that 
afforded by embryotomy. It is here that difference of opinion exists. 
Baudelocque admitted Cesarean section in cases with a conjugate 
diameter under 24 inches; Cazeaux, under 2 inches; Farnier, 2 inches, 
and Depaul, from H to 2^ inches when the child was alive, and under 
1^ inch when the foetus was dead. Stolz advocated Cesarean section 
whenever the child was alive, and could not be brought through the 
natural passage. Other authorities lay down the limits as follows: 



Scanzoni, under. . , 
Naegele. under.. . . 
Spiegelberg, under 



3 inches 



Barnes, under H inch. 

Playfair, under 1-^ " 

Leishman, under . . H " 



Of late years, the good results following Cesarean section in the hands 
of Cameron, Leopold, Sanger and other operators, have materially 
changed the views of many authors, who now favour Cesarean section 
more than they have done in the past. 

Lusk, at the International Congress held at Washington in 1887, de- 
clared that Cesarean section was preferable to embryotomy, even with 
a conjugate diameter from %\ to 3 inches, when the child was alive. 

It can well be urged that — 

(1) Embryotomy in a very contracted pelvis is as dangerous to 
the mother as Caesar ean section. 

(2) Embryotomy always sacrifices the life of the child, while 
Cesarean section gives a living child. 

(3) No person has any right to sacrifice a child where they can 
save it without exposing the mother to any additional risk. For these 
reasons the operation should be one of election when the child is 
alive, and it should be performed before the patient is exhausted; in 
fact, early after labour has commenced, or even at full term before 
labour sets in, especially in multipara?. In all cases it should be done 
before rupture of the membranes, and if possible the patient should 
be placed under the care of an experienced operator. 

Little difficulty is experienced in obtaining the consent of the 
patient and her friends, and it is better to have her under observation 
previous to the operation, so as to regulate her diet, and have her pre- 
pared for operation beforehand. 



464 A TEXT-BOOK OF GYNECOLOGY 

A very important point in favour of Cesarean section is that the 
Fallopian tubes can be tied and divided, so as to prevent subsequent 
conception, whereas embryotomy may require to be performed ten or 
a dozen times. 

Besides deformity of the pelvis, other conditions, such as tumours 
or cancer of the cervix uteri, may exist, which would demand either 
Caesarean section or some modification of it. 

If the child is dead and the conjugate diameter not under 1-J inch, 
Cesarean section should be done. 

Eousset, the earliest writer upon this subject, recognised two classes 
of indications, the one furnished by the foetus, and the other by the 
mother. Under the first category he placed excessive size of the foetus, 
monstrosities, and faulty positions. Under the second, he placed 
marked contractions from whatever cause. Some operators would 
include placenta praevia and puerperal convulsions. Caesarean section 
might be advisable in some cases of eclampsia, but a skilful obstetri- 
cian would never think of such procedure in the case of placenta 
praevia. In fact, the operators who advocate this step are surgeons 
who have little or no experience in obstetrical practice. 

Our decision for operation should be based upon the degree of 
contraction of the pelvis, the size of the child's head, and its reduci- 
bility, unless the obstruction is due to some other cause, such as cancer 
or the presence of a tumour in the pelvic cavity. 

Every practitioner should be able to form a fair estimate of the 
amount of contraction, as it is easier to measure a contracted pelvis 
than a normal one, and it does not require a highly skilled obstetrician 
to say before labour has commenced, or during the early stage of the 
process, that the diameter of the pelvis is, or is not, less than 3 
inches; and, as a matter of fact, such a pronouncement should be 
within the skill of the ordinary practitioner, who should be more than 
a generally useful person, otherwise he will sink to the level of an 
ignorant midwife. Not only must he be able to form an estimate of 
the amount of contraction, but by patient study of normal cases, he 
should qualify himself to form an opinion as to whether it will be 
impossible for a living child to pass, and also whether under the diffi- 
cult circumstances in which he may be placed, it would not be better 
to send the patient where Caesarean section could be safely performed, 
than to extract a mutilated foetus through a minimum diameter. 

With a diameter under %\ inches, where engagement of the head 
is impossible, no one should hesitate to advise Caesarean section, 
although there will always remain cases, as where the child is dead 
or a subject of hydrocephalus, in which craniotomy may be resorted to. 

Experience alone will enable one to avoid extreme measures in 
cases where the conjugate diameter measures more than 3 inches; 
in such cases, the skilled practitioner will weigh the chances between 
premature induction of labour and symphysiotomy. 

There can be no question that Caesarean section is a highly dan- 



CESAREAN SECTION AND ITS MODIFICATIONS 465 

gerous operation, but the danger, it should be remembered, de- 
pends for the most part on delay, and death most frequently results, 
not so much from the operation, as from previous operative abuse, 
which is the just term for all injudicious attempts to extract the foetus 
through a deformed natural passage. 

Success depends upon prompt interference before the patient is ex- 
hausted, as then there is less danger from hemorrhage, delayed shock 
or peritonitis. 

Y\ 'lien abdominal section has been resolved upon, another question 
presents itself, namely, whether Caesarean section or Porro's operation 
is preferable. If the former, there still remains to be decided whether 
the operation shall be accompanied or followed by a removal of the 
ovaries, or the patient be sterilized by the simple expedient of tying 
and dividing the Fallopian tubes. This has been done by Cameron in 
about fifty cases and no harm has resulted, although theorists would 
have it believed that such a procedure would be surely followed by 
hematocele. When there is a choice of operation, Cesarean section 
is to be preferred, as it can be completed much sooner, and is free from 
"the danger of shock and peritonitis which may complicate Porro's 
operation. 

The preparation of the patient will depend upon the urgency of 
the case. When she is under observation, it is better to confine her 
to bed for a couple of days beforehand, and the bowels should be 
moved by an enema and a slight laxative. The abdomen is washed and 
gently scrubbed, and the parts shaved while the vagina is cleansed and 
rendered aseptic. The preparation in fact is the same as for any other 
abdominal section. The operator and his assistants who have to do 
with the case must be exceptionally careful in cleansing and disinfect- 
ing their hands, while the chief nurse should see that the instruments 
and sponges are sterilized and counted. 

Very few instruments are necessary. The list should comprise 
the following: 

Scalpels 2 Xeedles. Hagedorn's 2^-inch straight . ^0 

Blunt-pointed bistoury . . . . 1 Pessary, compression 1 

Forceps, pressure 8 Silk, antiseptic. 

Dissecting 2 Silkworm gut. 

Scissors. Adhesive plaster. 

Director 1 Dressings. 

The catheter should always be passed into the bladder shortly be- 
fore operation. The needles should be threaded in pairs beforehand, 
with Xo. 3 Chinese twist silk ligatures, about 20 inches long, and placed 
in a towel wrung out of l-to-30 carbolic solution, ready for use. 

Palpation will reveal the position of the foetus, and this is all the 
more important, as from this the attachment or site of the placenta 
will be known. 

Cameron's experience in Cesarean section has shown him that in 
dorso-posterior positions the placenta is attached upon the anterior 
31 



466 



A TEXT-BOOK OF GYNECOLOGY 



wall, while in dorso-anterior positions the placenta is upon the pos- 
terior wall. Thus: 

(a) In the first cranial position, or O.L.A., the placenta will be 
found upon the posterior wall, and somewhat to the right side. 

(b) In the second cranial position, or O.D.A., the placenta will be 
upon the posterior wall, and somewhat to the left side. 

(c) In the third cranial position, or O.D.P., the placenta will be 
upon the anterior wall, and somewhat to the left side. 

(d) In the fourth cranial position, or O.L.P., the placenta will be 
upon the anterior wall, and somewhat to the right side. 

The foetus and placenta will be found in the same relation in the 

various pelvic positions. 

From this information it is easy to know when the uterine incision 

is likely to cut down upon the placenta, and an idea can also be formed 

as to how to extract the foetus. 

The Operation. — The abdominal incision should be made in the 

median line as in ovariotomy, and it will vary in situation according 

to the distention of the ab- 
dominal wall. 

Thus, if the abdomen does 
not droop (Fig. 200), an inci- 
sion from 5 to 6 inches in 
length may be obtained with- 
out extending beyond the um- 
bilicus; but when it is pen- 
dulous (Fig. 201), the incision 
must of necessity extend 
more or less above the um- 
bilicus. 

, Before opening the uter- 
us, the operator should satisfy 
himself that that organ is not 
only in the median line, but 
that it is not twisted upon its. 
axis. This is settled by locat- 
ing the position of the Fallo- 
pian tubes by means of the 
fingers. He will frequently 
find the left tube more or 
less in front, as the uterus is 
•usually rotated to the right. 

This displacement must be corrected, and, if necessary, an assistant 

can easily keep the uterus in position by pressing with his hand on 

the right side. 

When the placenta has its attachment upon the anterior wall the 

site is seen to bulge, and upon palpation has a fluctuating feeling akin 

to that of a large pointing abscess. 




Fig. 200. 



If the abdomen does not droop." — 
Cameron. 



CESAREAN SECTION AND ITS MODIFICATIONS 



467 



The next point is to open the uterus with as little loss of blood 
as possible, and this can be done by placing a flat vulcanite pessary 
upon the uterine wall around the point to be incised (Fig. 202). 

The operator, with the fingers of his left hand, applies pressure 
upon the pessary, while his assistant does the same on the opposite 
side. The incision is then made with two or three strokes of the scal- 
pel, and the blood sponged away by the assistant with his right hand. 
After this has been done, no more bleeding takes place until the 
placenta is attacked in front, as the pressure with the pessary thor- 
oughly prevents even oozing. Care should be taken not to puncture 
the membranes, which will soon be observed and recognised by their 
pearly colour. If the placenta intervenes, this method of pressure 
is beneficial, not only in preventing bleeding, but also in permitting 
observation of its tissue, which is recognised by its darker colour. 

Whenever the membranes are reached, a director is placed within 
the opening, which is then enlarged with a blunt-pointed bistoury 
upward and downward as far as the pessary will admit. At this stage, 
the compression pessary is removed and the incision extended upward 
and downward sufficiently to permit the passage of the foetus. The 
extension of the incision 
downward should be limited, 
as it is likely to interfere with 
proper contraction of the 
uterus. Should the placenta 
intervene, it must be dealt 
with as a placenta previa 
after completing the incision, 
that is, either separated upon 
one side, or if central, pierced 
by the hand. There must be 
no hesitation in extending 
the incision, which is made 
upward and downward from 
within outward in each direc- 
tion with a blunt-pointed bis- 
toury, to the length of about 
5 or 6 inches. The left hand 
is inserted without rupturing 
the membranes till the head 
is being turned out, or the 
feet grasped, and then the 
child should be extracted 
without delay. On no ac- 
count should the hand be 

withdrawn after its insertion, unless during extraction of the foetus, 
as the uterus speedily contracts. If the shoulder presents, a hand 
should be placed upon it to prevent its expulsion, as it adds very 




Fig. 201.— "When it is pendulous, the incision 
must extend more or less above the umbili- 
cus." — Cameron (page 466). 



468 



A TEXT-BOOK OF GYNECOLOGY 



much to the difficulty when any portion of the child's body is allowed 
to protrude. 

The child having been extracted, the assistant places a large flat 
sponge over the upper angle of the abdominal incision, to prevent the 
bowels from escaping, and then with both hands grasps the uterus, 
so as to prevent bleeding. 

The cord having been tied and divided, the placenta is immediately 
removed with the left hand, great care being taken to secure the re- 
moval of all membranes and to prevent the entrance of blood into 
the peritoneal cavity. The assistant now everts the uterus from the 
cavity, and pushes a flat sponge behind it. The lips of the uterine 
wound are next everted, the assistant grasping the upper angle and 
wall with his right hand, and the lower angle and wall with the left. 
While the assistant holds the wound thus, the operator immediately 
inserts the silk ligatures, beginning at the middle, each suture grasp- 
ing the entire wall with the exception of the mucosa (Fig. 203). From 
seven to ten sutures should suffice, as, with the contraction of the 
uterus, the incision is greatly diminished. 

This accomplished, the sutures are gathered up, a large flat sponge 
laid over the anterior wall, and another behind. Firm compression or 

kneading is then made 
through the sponges 
with the result that the 
uterus contracts firmly. 
The assistant should 
again seize the uterus 
as before, while the op- 
erator ties the sutures. 
When this has been ac- 
complished, the whole 
organ is enveloped in a 
large, warm, flat sponge, 
and firm compression is 
again made so as to in- 
sure thorough contrac- 
tion. Should any ooz- 
ing appear at the nee- 
dle punctures, a second 
warm sponge should be 
applied, and very slight 
compression will suffice 
to overcome any tend- 
ency to relaxation. 
Should the peritoneal 
edges gape at any points, a few superficial fine sutures should be in- 
serted to bring the margins together. 

The performance of hysterectomy for bleeding is bad treatment, 




Fig. 202. — "Placing a flat vulcanite pessary upon the 
uterine wall around the point to be incised." — Cam- 
eron (page 467). 



CESAREAN SECTION AND ITS MODIFICATIONS 



469 



and indicates that the operator has lost his nerve, as pressure with 
a warm sponge with both hands never fails to secure thorough con- 
traction. 

Several operators advise the introduction of a drainage tube 
through the cervix and vagina, and the leaving it there to act as a 
drain. Nothing could be worse. Of course, it is the procedure of a 
surgeon, but every one who has practised midwifery knows that the 
presence even of a clot in the uterus may lead to serious hemorrhage. 
Such a body as a tube, if 
not expelled, would in- 
duce hemorrhage, disten- 
tion of the uterus, and 
bursting of the incision 
with speedy death of the 
patient. This is no mere 
theory, but is what has 
actually taken place 
where drainage has been 
resorted to. On no con- 
dition should the uterine 
cavity be washed out or 
medicated in any way. 
The less the parts are in- 
terfered with the better. 

After the ligatures 
have been cut short, the 
next step is to ligature 
the Fallopian tubes with 
antiseptic silk and divide 
them, in order to prevent 
future conception. Of 
course, the consent of the 
patient for this procedure 
should be obtained be- 
forehand. Two ligatures 
are tied upon each tube, 
which is then divided be- 
tween those points. This 

method is effective, and leads to no complications or bad results, nor 
is menstruation interfered with. The cavity is next cleaned by the 
removal of all clots, etc., and the uterus replaced. The external wound 
in the parietes is closed in the usual way with silkworm sutures. The 
vagina should now be cleansed of all clots and sponged out, after 
which an antiseptic pad should be applied to the vulva. 

The wound should be dusted with iodoform, and a few layers of 
gauze placed over the wound. This should be secured with plaster, 
to prevent both slipping of the dressing and strain on the sutures, 




Fig. 203. — " The operator immediately inserts the silk 
ligatures, each suture grasping the entire wall with 
the exception of the mucosa." — Cajiekon (page 468). 



470 



A TEXT-BOOK OF GYNECOLOGY 



in case of sickness or cough. A sheet of gamgee or other dry absorbent 
dressing is next applied, and then the bandage. 

The after-treatment consists of sips of warm water, say a teaspoon- 
ful every fifteen minutes for twelve or twenty-four hours, after which 
milk and soda may be given in increasing quantities. For a few 
nights, half a grain of morphine in suppository is given. The urine 
should be drawn off every six hours for two or three days, care being 
taken to cleanse the parts thoroughly before doing so. 

On the fourth day, an enema of two teaspoonfuls of glycerine in 
two ounces of soapy water is administered, and, if necessary, some 
slight aperient by the mouth. The bowels having been moved, the 
patient is allowed, chicken soup, fish, eggs, beef tea, etc. If the child 
is to be nursed, it may be put to the breast on the second or third day. 
The abdominal sutures may be removed in from ten to fourteen 
days, and the patient allowed to rise at the end of four weeks. She 
should always wear an abdominal belt, and should be warned against 
kneeling when scrubbing floors, etc., as this is apt to induce hernia 
from pressure and stretching of the cicatrix. 

In review, it may be explained that rupture of the membranes, 
either intentionally or by labour, means a contraction of the uterine 
wall, and as a consequence a greater wounding of the uterine tissue, 
in order to secure a sufficient opening to extract the child. Some 
operators, instead of using manual or pessary compression to prevent 
bleeding when opening the uterus, employ an elastic ligature. The 
uterus is first everted, and the elastic ligature is then passed round 
the cervix. This not only necessitates a much larger abdominal inci- 
sion, but also induces asphyxia of the foetus and causes inertia of the 
uterus, as the organ does not so readily respond to kneading. Its 
employment is therefore conducive to hemorrhage. Veit, Doleris, 
and Pa jot, have blamed it for causing death from hemorrhage, and 
Zweifel, Sanger, and Lusk, have also noticed this complication. 

Carniso advised the 
early removal of the 
ligature. 

Sanger's method is 
another way of dealing 
with the uterine incision 
(Fig. 204). In this pro- 
cedure, the muscular 
wall of the uterus is 
closed with from ten to 
fifteen sutures which ap- 
proximate to, but do not 
include, the mucosa, and 
between each suture two superficial sutures are inserted to unite 
peritoneum to peritoneum. Formerly, the peritoneum was separated 
from the muscularis, and a wedge-shaped piece of muscularis was 




Fig. 204. — " Sanger's method is another way of dealing 
with the uterine incision." — Cameron. 



CESAREAN" SECTION AND ITS MODIFICATIONS 471 

Temoved from each side, the base of the wedge being outermost. 
This done, the peritoneal flaps were folded into the wound and se- 
cured by the superficial stitches. Such a detailed process is quite 
unnecessary, as the sutures as recommended by Cameron secure 
perfect apposition, not only of the muscular tissue, but also of the 
peritoneum. In fact, most operators now make use of only eight 
or ten deep sutures, and reserve superficial sutures to secure con- 
tact where there is any gaping between the stitches. Such uneven- 
ness can be readily avoided by beginning in the middle and working 
toward each end, and by taking care to keep the sutures at regular 
intervals. 

Porro's Modification. — The fatal results following the early Cesa- 
rean section led to a modification of the operation. It had been found 
by experiment that the uterus in pregnant rabbits could be removed 
with better results than by simple section, and therefore it was con- 
cluded that similar results would follow in the case of women. 

Blundell, in writing upon this subject, said such a method might 
prove an eminent and valuable improvement, but he also wrote, in 
speaking of deaths from peritonitis after Cesarean section, that ex- 
perience sometimes contradicted our most cherished opinions, and that 
something of the kind would be found to occur in the cases under 
consideration, as he had no doubt that the risk of diffused peritonitis 
had been greatly exaggerated. How his surmise has proved true, is 
seen in the present-day position of abdominal surgery. 

Acting on the lines suggested, Storer, of Boston, in 1868, first prac- 
tised amputation of the uterus after section. The case was one of 
pregnancy complicated with a fibroid of the uterus. He was inter- 
rupted by such an alarming hemorrhage that he had to remove the 
body and fundus with the ovaries, but his patient died three days after- 
ward. This was an operation of necessity. 

Porro first performed the operation as a matter of choice, as he 
•considered it impossible to secure the uterine incision in Cesarean sec- 
tion so fully as to prevent the flow of blood and septic fluid into the 
peritoneal cavity. The results obtained under antiseptics in other 
abdominal operations encouraged him to make the attempt, and in 
1876 he did so with happy results. Others took up the operation, and 
very quickly the old Cesarean section was superseded by it; but only 
for a few years, for Cesarean section can noAv be performed without 
the slightest danger from bleeding, peritonitis, septicemia, or other 
dangers, that Porro's operation sought to avert. 

At the present day, Porro's operation is an operation of exception, 
that is, only necessary in some conditions, such as serious rupture of 
the uterus, or where labour is obstructed by a large fibroid. As regards 
the steps of the operation, it is at the beginning similar to Cesarean 
section. But after the uterus has been emptied it varies, inasmuch 
as at this point the uterus is everted and an elastic ligature applied 
round it, just above the os internum. The uterine tissues are then 



472 A TEXT-BOOK OF GYNECOLOGY 

compressed until the bleeding lias ceased. Then the uterus is re- 
moved, the stump secured outside the abdominal wound, and main- 
tained in position by needles and a serre-nceud. 

Porro, upon emptying the uterus, transfixed it with a trocar and 
cannula at the union of the body and cervix. He then withdrew the 
trocar and passed two silver wires through the cannula, which was also 
withdrawn and the wires tied, one upon the right and the other upon 
the left side, including in their grasp the ovaries and tubes. This 
done, the uterus and appendages above the wires were cut away, while 
the stump was secured outside. The method has been improved by 
transfixing with needles and ligating with a serre-nceud instead of with 
separate wires. 

The stump is dusted with iodoform, and dressed with gauze all 
round. The needles should be raised to allow of proper packing. A 
layer of sublimated gamgee or other dry absorbent dressing should be 
placed over all. It may require to be dressed daily, and the ligated 
portion usually separates about the tenth day, but the raw cavity re- 
quires regular dressing until perfectly healed. 

It was urged as an important factor that Porro's operation pre- 
vented future conceptions, but this end is gained in Cesarean section 
by the more simple method of tying and dividing the tubes. 

Some operators now prefer to remove the entire uterus. 



CHAPTER XXXI 

MALFORMATIONS AND DISPLACEMENTS OF THE 
FALLOPIAN TUBES 

Absence and defective development of the tubes — Supernumerary and accessory 
tubes and ostia — Displacements of the Fallopian tubes. 

The Fallopian tubes develop from the upper ends of the two 
Miillerian ducts. Their anlagen are first solid and cordlike and later 
become hollow tubes, and their lower limit is marked hy the anlage 
of the round ligament. Below this level the Miillerian ducts unite 
to form the uterus and vagina. Their malformations may be marked 
by the characters of defect, of excess, or of altered relation. During 
foetal life each Fallopian tube shows several spiral convolutions. 

Absence and Defective Development of the Tubes. — Absence of both 
tubes is very rare, and when it occurs it is nearly always associated with 
absence of the uterus. A less rare anomaly is absence of one tube, 
and in such a case the corresponding ovary is said to be usually wanting 
also; but this is probably less often so than has been thought, for the 
gland may be present in a rudimentary state, as in the specimen de- 
scribed by Blot (Comptes renclus de la Societe de oiologie, 2. s., vol. iii, p. 
176, 1857), or in an unusual position in the abdominal cavity. Very fre- 
quently the defect is associated with the uterine malformation known 
as uterus unicornis; it is easy to understand this combination of de- 
fects when it is borne in mind that the tube and the corresponding 
half of the uterus are both developed from the same duct of Muller. 
Unilateral absence of the tube is not necessarily accompanied by in- 
terference with the reproductive functions, for Chavannaz (Journal de 
medecine de Bordeaux, vol. xxvi, p. 361, 1896) has recorded the case of a 
woman of sixty who had menstruated regularly and had borne three 
children, and who yet possessed (as was found out at the autopsy) 
neither tube nor ovary on the right side. The kidney of the same 
side may also be wanting, as in Edridge-G-reen's case (British Medical 
Journal, 1895, vol. i, p. 416). The Fallopian tube may be absent 
in part, for Ballantyne and Williams (Structures in the Mesosalpinx, 
p. 26, 1893) have described a case of genital tuberculosis in which the 
outer two thirds of the right tube was completely wanting and the 
inner third ended in a tapering conelike extremity (Fig. 205). Some- 
times the tube shows its rudimentary development by its solid state 
or by imperforation of its abdominal end, anomalies which a knowledge 

473 



474 A TEXT-BOOK OF GYNECOLOGY 

of embryology makes it easy to comprehend. Another form which 
rudimentary development of the tube may take, is persistence of the 
spiral convolutions which are normally present in fcetal life; it is 
doubtful whether these twists represent a return to the foetal state or 
a continuance of it; they must predispose to the occurrence of hydro- 
salpinx, and they may lead to sterility and dysmenorrhea. 




Fig. 205. — " A case of genital tuberculosis in which the outer two thirds of the right tube 
was completely wanting and the inner third ended in a tapering conelike extremity." 
— Ballantyne (page 473). 

Supernumerary and Accessory Tubes and Ostia. — Cases of super- 
numerary or double tubes are exceedingly rare; but instances of acces- 
sory ostia or of small tubes attached to the broad ligament or to the 
Fallopian tube itself are comparatively common. It is not difficult to 
understand why this should be so, for in the former case it is necessary 
to suppose the existence of two Mullerian ducts on one side, while in 
the latter the condition may be explained by anomalous development 
of a single duct. An example of true double tube (on the right side) 
was reported by Winckel (Lehrbuch, p. 595, 1886); there was a third 
ovary lying in front of the uterus, and attached to it was a cordlike 
structure with a fimbriated end which passed to the right side and was 
connected with the right Fallopian tube; the patient was sterile. The 
case described by Ruppolt (Arcliiv fur Gynakologie, vol. xlvii, p. 64:6, 
1894) must be looked upon as one of constriction of a Fallopian tube by 
foetal peritonitis, and not as true duplication of the tube. With regard 
to Wetherill's case of " supernumerary oviducts " (American Journal 
of Obstetrics, vol. xxxiv, p. 373, 1896), some doubt must also exist as to 
whether the tubes running in the broad ligaments below and parallel 
with the normal Fallopian tubes were really salpingeal in nature or not. 

Accessory ostia and tubes are, as has been said, not so uncommon. 
Ballantyne and Williams (Structures in the Mesosalpinx, p. 25, 1893) met 
with two instances of accessory ostia in sixty-one pairs of tubes from 



MALFORMATIONS OF THE FALLOPIAX TUBES 



475 




Fig. 206. — " Usually, one accessory ostium only is 
present." — Ballaxtyxe. 



consecutive post-mortems at the Edinburgh Boyal Infirmary. Usually, 
one accessory ostium only is present (Fig. 206), and it is situated on 
the upper margin of the tube not far from its normal ostium; but Fer- 
raresi (Annali di ostetricia, ginecologia e pediatric! , vol. xvi. p. 521, 1894) 
has put on record a re- 
markable case in which 
there were six ostia in all. 
They are either sessile on 
the normal tube or have 
longer or shorter pedicles 
connecting them with it. 
These pedicles may be hol- 
low, and generally the 
ostia are surrounded by 
fimbria 3 and communicate 
with the tubal lumen. 
They may arise either from 
imperfect closure of the 
groove in the germinal epi- 
thelium which ultimately 

becomes the upper end of the duct of Muller, or from secondary opening 
of the duct after it has been closed. The structures which have been 
described must not be confounded with what have been called " tubal 
appendages " or " pedunculated tufts of fimbria?.* 7 These are solid 

stalks bearing nu- 
merous fimbria? on 
their free end, and 
they usually spring 
from the broad liga- 
ment in the neigh- 
bourhood of the par- 
ovarium. Ballantyne 
and TVilliams (loc. 
cit.. p. 15) have 
shown how frequent- 
ly stalked cysts of 
the tubules of Ko- 
belt occupy this po- 
sition (Fig. 20?), and 
it is quite possible, 
as Bland Sutton sug- 
gests, that the pe- 
dunculated tufts of 
fimbria? are simply ruptured cysts of Kobelrs tubes. A com- 
parison of Ballantyne and Williams's representation of such a cyst 
and Kube's case of accessory tubal appendages (Fig. 208) will 
strengthen this view. It is noteworthy, however, that in the dis- 




Fig. 207. — "Frequently stalked cysts of the tubules of Kobelt 
occupy this position." — Ballaxtyxe. 



476 A TEXT-BOOK OF GYNECOLOGY 

cussion which followed the reading of Rube's paper (Journal Akou- 
sclierstva I Gienskich Boliesney, vol. ix, p. 458, 1895), Massen stated that 
so-called parovarian cysts might arise from these accessory tufts of 
fimbriae. The question must, therefore, be left undecided in the mean- 




Fig. 208. — " Kube's case of accessory tubal appendages." — Ballantyne (page 475). 

time. Tubal diverticula are sometimes met with, and it has been haz- 
arded that their rupture, followed by the prolapse of the tubal folds 
through the opening thus formed, may lead to the production of an 
accessory ostium. 

From the clinical standpoint, accessory tubal ostia and diverticula 
are not unimportant; indeed, the opinion has of late years been grow- 
ing that they stand in very close relation with the causation of extra- 
uterine gestation. Thus Henrotin and Herzog {Revue de gynecologic 
et de chirurgie abdominale, vol. ii, p. 633, 1898) have reported two cases 
in which they regarded tubal malformations as the cause of ectopic 
pregnancy: in one, the abdomen was opened for symptoms of tubal rup- 
ture, and it was found that below the right tube was a small accessory 
tube with a complete ostium abdominale, and in it a sac containing 
blood clot, decidual cells, and chorionic villi; in the other, the uterus 
and appendages were removed for long-continued pelvic symptoms, and 
it was seen that from the left Fallopian tube near its middle a diver- 
ticulum projected toward the uterus, and in this there were also blood 
clot, decidual cells, and chorionic villi. On the other hand, an acces- 
sory ostium tubas may render possible the occurrence of pregnancy 
when the normal tubal ostia on both sides of the body are closed by 
inflammatory adhesions, as in the remarkable case described by Sanger 



DISPLACEMENTS OF THE FALLOPIAN TUBES 477 

(Monatsschrift fur Geburtsliulfe und Gyncikologie, 1895, vol. i, p. 21, 
Bovee (National Medical Review, July, 1899) reported a case in which, 
in an operation for adhesion of the appendages and retroversion of the 
uterus, examination of the right appendage showed two fimbriated tube 
ends. Through the upper tube a probe could be passed almost to the 
uterine cormi; the other was permeable to the probe for about 2 inches, 
but as the passage of a probe all the way to the uterine from the am- 
pullar end of a tube is rarely possible, it seemed probable that there 
were really two similar, normal tubes in this case. 

Displacements of the Fallopian Tubes. — The tube, like the ovary, 
may be congenitally displaced. It may, for instance, be at a higher 
level than normal in the abdominal cavity. In the case of a newborn 
infant, J. W. Ballantyne (Transactions of tlie Edinburgh Obstetrical 
Society, vol. xv, p. 56, 1890) found the right Fallopian tube adherent, 
through foetal peritonitis, to the peritoneal aspect of the caecum; and 
M. L. Harris (American Gynecological and Obstetrical Journal, vol. viii, 
p. 45, 1896) discovered, during abdominal section performed for men- 
strual pain, that the right tube was much longer than usual and passed 
to the right ovary which lay on the psoas magnus as high as the bifur- 
cation of the aorta. A case is on record (Hitter, Monatsschrift fur 
Geburtsliulfe, vol. xxv, p. 421:, 1865) in which the tubes were displaced 
backward, and were united behind the uterus by their ostia, forming a 
ring. Another type of tubal displacement is herniation. Just as 
hernia of the ovary into the inguinal canal may occur, so the tube may 
find its way in the same direction. Usually, the tube is herniated along 
with the ovary (see Malformations of the Ovary), but in exceptional 
cases it has been met with alone. Thus, Pierre AViart (Bulletins et 
memoires de la Societe anatomique de Paris, 6. s., vol. i, p. 59, 1899) 
has reported the case of a six-months'-old child with hydrocephalus, in 
which the uterus was displaced toward the left side, the tube and round 
ligament of the same side were engaged in the abdominal opening of 
the inguinal canal, and the tube inside the canal was disposed in the 
shape of an almost complete 0, the fimbriated end coming nearly into 
contact with the part immediately projecting from the orifice. The 
ovary lay near to the opening but did not engage in it. It is probable 
that this form of hernia is more common than has been thought; it may 
be present at, or soon after, birth and be reduced by the rearrangement 
which takes place among the abdominal and pelvic viscera in the first 
year of life. If it persists, it may give rise in later life to dysmenor- 
rhea, perhaps also to sterility. 



CHAPTEE XXXII 

NEOPLASMS OF THE FALLOPIAN TUBES 

Benign neoplasms: papillomata; cystomata; lipomata; fibromyomata — Malignant 
neoplasms: carcinomata; sarcomata. 

Adventitious growths of the Fallopian tubes are of comparatively 
rare occurrence and of but relatively small clinical importance. Little 
has been written upon this subject, and, for our present knowledge, 
we are indebted chiefly to Bland Sutton, Orthmann, Clark, and Doleris. 
A systematic study of these growths must be based upon the fact em- 
phasized by Coe that the Fallopian tubes are but extensions of the 
uterus itself and contain the same histologic elements; and that they 
are, therefore, liable in a certain degree to the same neoplastic changes. 
Growths originating in these structures, like those originating else- 
where, are divisible into benign and malignant. 

The benign neoplasms of the Fallopian tubes, so far as described, 
are (a) papillomata, (b) cystomata, (c) lipomata, (d) fibromyomata. 

Papillomata occurring in the Fallopian tubes have been carefully 
studied by Clark. Doran was the first to call attention to the subject 
which has been carefully elaborated by Sanger and Barth. Bland 
Sutton, who has reported two cases, has demonstrated the fact that the 
mucous membrane of the Fallopian tubes contains glands the adeno- 
matous tissue of which may become the starting point of true homolo- 
gous papillomata. This theory, however, has been rejected by Sanger 
and Barth. Papillomata in the tubes manifest themselves by the de- 
velopment of a tumour, which is generally the first symptom to attract 
the patient's attention. This growth becomes painful and may confine 
the patient to bed with repeated attacks of peritonitis. The tumour 
may be globular, elastic, and fluctuating, and may possess a varying 
degree of mobility. It may be small or it may be large enough to pro- 
duce lateral displacements of the uterus with obscuration of its fundus. 
In Slansky's case, which comprised the basis of Clark's article, the 
tumour was about half the size of a man's head, presenting at one spot 
an amputated surface about 4 centimetres square, at one point of 
which was a short pedicle having the appearance of the enlarged 
uterine end of the Fallopian tube; close to the point of amputation 
was an irregularly torn opening through which the contents of the 
cyst had escaped. The external surface of the tumour was smooth, 
containing a few large dilated blood vessels and showing in the deeper 
478 



NEOPLASMS OF THE FALLOPIAN TUBES 479 

layers occasional necrotic areas. The internal surface was covered with. 
a thick papillary growth, consisting of multiple funguslike excres- 
cences which, in some areas, were massed together in thick, dense 
clumps, presenting a typical cauliflower appearance. The papillae 
varied from delicate fimbriae to large, fusiform projections containing 
small cysts. There were occasional areas devoid of excrescences. The 
morbid histology of tubal papillomata is accurately described by Clark 
(Bulletin of the Johns Hopkins Hospital), who found that sections 
through the circular folds showed a greatly attenuated cyst wall meas- 
uring only 0.05 to 0.1 centimetre in thickness. Peritoneum, circular 
muscle fibres, a thin stratum of connective tissue, longitudinal muscle 
fibres, followed by a denser layer of connective tissue upon which rested 
one layer of columnar epithelium, arranged in regular order, were shown 
upon the slide in consecutive striae. Except in the baylike projections 
between the folds, the epithelium was nonciliated, and, even in these 
spaces, the ciliated cells were only rarely found. Clark's further de- 
scription of the microscopic appearances is as follows: 

" Xumerous large dilated blood vessels occupy the connective-tissue 
layer beneath the epithelium. The folds of the Fallopian tube, as such, 
are no longer present, but are represented by sessile and pedunculated 
papillary growths. 

" The low sessile projections are composed of dense connective tis- 
sue, like that seen in chronic inflammation of the tube, whose cells ex- 
tend at right angles from the underlying circular fibres, forming warty 
prominences clad with one layer of columnar epithelium which gradu- 
ally shades off into the low columnar and cuboidal variety as the domes 
of the projections are reached. Besides the sessile excrescences there 
are a few long, slender processes to which are attached daughter off- 
shoots. The main stem in all instances contains large dilated blood 
vessels. The connective tissue forming the stroma of these papillae 
shows a marked variation in its structure in different areas. At the 
bases of the papilla? the cells are closely crowded together and contain 
deeply-staining spindle-shaped nuclei. This appearance is maintained 
until the apices or domes of the growths are approached, when the 
cells gradually become hyaline, and in turn shade off into a pure mucoid 
degeneration. 

" Sections from the thicker portions of the cyst wall (0.5 centimetre 
thick) show unstriated muscle fibres scattered very sparsely among 
the connective-tissue fibres which make up the chief part of the sec- 
tion. The internal surface of the cyst wall is covered with innumer- 
able, vigorous growing papillomata, whose main stems extend far out 
into the lumen of the cyst, forming the most complicated, coral-like 
systems. The offshoots have, in many instances, coalesced, forming 
spaces which contain small papillary growths. 

" In some instances the main stems have become adherent to each 
other, inclosing much larger giandlike spaces. The mucoid degenera- 
tion noted above is even more marked here, and in the large fusiform 



480 A TEXT-BOOK OF GYNECOLOGY 

ends of some of the branches the entire stroma has undergone this 
transformation, giving the cystic appearance noted in the macroscopical 
description. Hemorrhage has occurred into some of these spaces con- 
taining the mucous tissue, leaving a granular debris which stains a 
bright yellow by Van G-ieson's method. 

" The ends undergoing degeneration are covered by one layer of 
shrunken cuboidal epithelium, which rests upon a thin layer of hyaline 
connective tissue. Besides the cystic spaces formed by the fusion of 
the papillomata, others are found occupying a deeper portion of the 
cyst wall, lined by cuboidal epithelium and surrounded by a dense con- 
nective-tissue stroma like those seen in c sacto-salpinx pseudo-follicu- 
laris.' (Martin.) 

" In one of these spaces a small papilloma is seen in process of 
formation. The single layer of cuboidal epithelium lining the cavity 
forms an uninterrupted line, except at one point, where it assumes a 
columnar shape and becomes heaped upon a delicate connective-tissue 
papilla projecting from the main stroma." 

The symptoms of papillomata of the ovary are simply those of an 
intrapelvic tumour. They are painful but not more so than certain 
dermoids. Their tendency to rupture of the tube or capsule in which 
they develop, results in the escape of blood and of the products of 
degeneration into the peritoneal cavity, causing inflammation of that 
membrane. In none of the cases so far reported, only six in num- 
ber, has a diagnosis been made before operation. The treatment con- 
sists in the removal of the tumour by abdominal section. In view of 
the fact emphasized by Williams that all papillomatous growths have 
a tendency to undergo malignant degeneration, this form of neoplasm, 
rare as it is, furnishes another reason for prompt intervention in the 
presence of a pelvic tumour of undetermined character. 

Cystomata of the Fallopian tubes are generally of rare occurrence, 
of insignificant size, and of but little clinical interest. They may 
originate either within the serous coat or the muscularis, although 
their favourite site of development is from the vestibular mucosa. It 
is probable that they are inflammatory products, in the sense that 
mucous follicles have become occluded and thus converted into re- 
tention cysts. Sutton has reported a large cyst which developed in 
the muscularis and attained the size of a walnut, the probable origin 
of which was similar to that observed by Kiwisch in the submucosa, 
and which was demonstrably of inflammatory origin. A. Martin has 
published an interesting picture showing the cysts and other growths 
that develop about the vestibule (Fig. 209). 

Lipomata can hardly be spoken of in the plural, when indicating 
these growths as they develop in the Fallopian tubes. Their existence, 
so far as available records indicate, depends upon the report of a 
single case by Eokitansky. The neoplasm in that case was about the 
size of a walnut. The condition is symptomless and without clinical 
interest. 



NEOPLASMS OF THE FALLOPIAN TUBES 



481 



Fibromyomata may develop from the muscularis of the tube. 
Hypertrophy and hyperplasia of this tunic are not infrequent sequelae 
of salpingitis, and have been noted by Sutton as accompaniments of 
fibroid degeneration of the uterus. These areas of hyperplasia may be 





Fig. 209. — " A. Martin has published an interesting picture showing cysts and other growths 
that develop about the vestibule." — Reed (page 480). 



more or less limited by bands of constriction which give to them the 
appearance of myomatous degeneration. As pointed out by Coe, how- 
ever, they are not true neoplasms. These latter are relatively of smaller 
size, rarely more than from 1 to 2 centimetres in diameter, although 
Speth's case, which is accepted as reliable, was about 4 centimetres in 
diameter. These nodules may be interstitial, but are generally sub- 
serous and pedunculated. They abound more in muscular than fibrous 
tissue. They belong to the curiosities of pathology, and are rarely 
productive of symptoms. 

Malignant neoplasms of the Fallopian tubes are (a) carcinomata 
and (b) sarcomata. 

Carcinomata occur in the tubes usually as the result of extension 
of the disease from the corporeal endometrium. It has been asserted 
that metastasis of carcinoma from the uterus to the tubes is of very 
rare occurrence. Kiwisch found carcinoma of the tube only 18 times 
in 73 cases of cancer of the uterus, and Dittrich in only 4 cases out 
of 94 of general carcinomatosis. Orthmann, in a communication on 
this subject to the Gynecological Society of Berlin {CentraTblatt fur 
Gyn'dkologie), stated that a careful research of the literature of the 
subject yielded accurate descriptions of only 13 cases, in 9 of which 
the uterus and in 4 the ovaries were primarily affected. The disease 



482 A TEXT-BOOK OF GYNECOLOGY 

may occur primarily in the tubes. This was true in 1 out of 3 cases 
occurring in Martin's clinic. The fact that metastasis to the tubes 
is of such rare occurrence is explained, according to Olshausen, by the 
distribution of the lymphatics, which do not favour the migration of 
morbific elements from either the ovaries or the uterus to the oviducts. 
Sarcomata are of infrequent occurrence in the Fallopian tubes. 
The reports of the few cases which have been recorded raise some doubt 
as to the exact character of the neoplasm. The histologic elements 
are usually so diverse that the growth itself is hardly susceptible of 
exact classification. The preponderance of connective-tissue elements, 
occurring in connection with other forms of cell growth, has gen- 
erally resulted in the designation of the tumour as a sarcoma, or, more 
properly, a myxosarcoma. These tumours rarely attain the size 
reached by true sarcomata in other localities. Their growth is gener- 
ally more rapid than that of benign neoplasms, or, indeed, of the 
papillomata, the benignity of which is open to suspicion. Their symp- 
tomatology is simply that of a pelvic tumour, the existence of which 
should always be regarded as an indication for an incision undertaken 
for diagnostic purposes. In this suggestion lies the correct indication 
for treatment of these eases. 



CHAPTER XXXIII 

INFECTIONS AND INFLAMMATIONS OF THE 
FALLOPIAN TUBES 

Infections in general — Bacteria of the Fallopian tubes in health — Bacteria of the 
Fallopian tubes in disease — Relations of infections to inflammations of the 
tubes — Catarrhal salpingitis — Morbid histology of salpingitis: (a) acute, (b) 
chronic — Hydrosalpinx — Hematosalpinx — Pyosalpinx — Symptoms and diag- 
nosis of salpingitis. 

Infections of the Fallopian Tubes. — The Fallopian tubes are fre- 
quently the seat of infection. It may be said that, aside from neo- 
plasms, which are rare, and malformations, which are still more rare, 
infections of the Fallopian tube cause, either directly or indirectly, 
practically all the diseased conditions which in those structures demand 
the attention of the practitioner. It is true that many of the in- 
fections of the Fallopian tube can not be distinguished from each 
other by present clinical methods; this fact, however, must not be 
accepted as a final barrier to either the present consideration or the 
future investigation of these conditions from the standpoint of their 
causation. The constant improvement in methods of investigation is 
resulting in the progressive revelation of new and important facts 
relative to the bacteriology and the histo-pathology of the Fallopian 
tubes, as of other structures of the body. "While this fact is recog- 
nised and acted upon, the outlook must be accepted as promising. 
Thus, Reymond (Annals of Surgery) found streptococci in a number 
of eases which a few years previously would have been considered 
sterile salpingitis, but in which, by means of improved methods, the 
micro-organisms were discovered. Practically all the progress which 
has been made in this department has been realized, step by step, by 
such painstaking investigations. The point at which we have arrived, 
justifies the consideration of all inflammatory diseases of the Fallopian 
tubes as of infectious origin, although the dominant micro-organism 
upon which the infection depends, can not be isolated in all cases. A 
systematic consideration of the subject must take into account (a) the 
bacteria of the Fallopian tube in health; (b) the bacteria of the Fal- 
lopian tube in disease; (c) the general pathology of inflammation of 
the tubes induced by infections in general; (d) individual infections; 
and (e) treatment. 

483 



484: A TEXT-BOOK OF GYNECOLOGY 

The bacteria of the Fallopian tubes in health have been investigated 
by Sinclair, who points out the fact that, from the bacteriological point 
of view, it is well to keep in mind that the Fallopian tube has two 
openings, one extremely narrow, connecting it with the cavity of the 
uterus, and the other, the wide abdominal orifice connecting it Avith 
the peritoneal cavity. 

Invasion of the tube by bacteria may occur from either end, or 
through its walls under special conditions. The cavity of the uterus 
in health is free from germs and so is the peritoneal cavity. Inva- 
sion through the walls of the tube only occurs in adhesion to the intes- 
tine or from bacterial disease in the pelvis. Consequently in a state 
of health the Fallopian tube is entirely free from germs. 

Witte examined freshly extirpated and apparently healthy tubes in 
11 cases. In 9 cases, the cultivation remained absolutely sterile. In 
one of the remaining cases he found both the staphylococcus and the 
streptococcus, in the other only a sparse growth of the staphylococ- 
cus. The corresponding uterus in each case was examined at the 
same time, and, in the cervical canal of the first, the streptococcus 
and staphylococcus were found. In the second uterus, the staphylo- 
coccus was discovered in the cavity of the body. In spite of the 
obvious cause of the presence of bacteria in the tubes, Witte drew 
the general inference that the healthy tubes might contain micro- 
organisms. 

Winter examined 40 tubes which had just been obtained by opera- 
tion. He employed the usual methods of cultivation in searching for 
bacteria, and, although there were a few exceptions of which he con- 
sidered the explanation satisfactory, he concluded that the healthy 
tube was free from bacteria. 

Menge examined 83 tubes obtained from 50 women operated upon 
for various reasons. Exact examination by the microscope and by 
cultivation experiments in various ways may be assumed. He came 
to the same conclusion as Winter, namely, that " the normal tube 
is always germ-free." 

It is possible that the tubercle bacillus may be found in or about 
the apparently healthy tube in very minute areas of infection, but it 
is a circumstance which must be extremely rare, and not to be dis- 
cussed here without entire disregard of proportion. The pathogenic 
bacteria of every other sort produce marked tissue changes immediately 
after invading the tube. 

The bacteria of the Fallopian tubes in disease are of extreme im- 
portance, for, as already stated, and as emphasized by Sinclair, among 
the diseases of the tubes which must be referred to bacterial invasion, 
we find all, almost without exception, with which we have to deal in 
gynecological practice. 

For the production of a serous collection in the Fallopian tube 
(hydrosalpinx), two things are necessary: on the positive side, the oc- 
currence more or less remotely of sufficient perisalpingitis to close the 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 485 

abdominal orifice; and on the negative, the absence of such an amount 
of bacterial infection as will permit the fluid distending the tube to 
remain clear. The most common form of hydrosalpinx, that with the 
walls thin and translucent owing to the great distention of the tube, 
usually shows signs of pre-existing inflammation in addition to the 
sealing up of the ostium abdominale; but it is hardly conceivable that 
any virulent bacterial infection at any previous time could leave so few 
traces of its existence. 

In the form of hydrosalpinx, where the walls are thick and com- 
paratively hard, the anatomical changes may be, and most likely are, 
produced by the work of pathogenic bacteria of such a modified viru- 
lence, or in such small quantity, as not to produce pyosalpinx. 

To leave theory and come to the results of the comparatively small 
amount of work that has been done in the bacteriology of hydro- 
salpinx; the examinations made by Menge on 20 cases of hydrosal- 
pinx and 3 of hematosalpinx gave an absolutely negative result. The 
usual care was exercised, and a great variety of cultivation methods were 
adopted, including the methods and media employed in the search for 
the bacillus tuberculosis, and yet the results indicated the entire ab- 
sence of any germs which could be seen with the microscope or culti- 
vated by any of our known methods. 

It is interesting to notice that the conservative method of dealing 
with hydrosalpinx by simple incision, or its equivalent, has received 
post-fact um justification from the bacteriologists. 

The bacteria of purulent inflammations (pyosalpinx) are beginning 
to be better understood. It is only a short time since we hardly knew 
of the existence of diseases of the Fallopian tubes. In the last decade 
and a little more, they have been more exactly and effectively studied, 
owing to the wealth of material obtained by the introduction of radical 
surgical treatment. The tendency now is to set down all the more 
severe forms to bacterial invasion, especially by the gonococcus and 
the pathogenic bacteria, which produce endometritis in childbed. Ever 
since Westermark, in 1886, announced the discovery of the gonococcus 
in the pus of a pyosalpinx, innumerable investigations to prove or 
disprove the bacterial origin of tubal disease have been undertaken, 
and the contributions to the bacteriology of the subject have been 
voluminous in the extreme, and, as usual, many-voiced and often con- 
tradictory. In addition to the study of the gonococcus and other 
pathogenic micro-organisms, many observations, both clinical and 
bacteriological, have been made upon the phenomena of tuberculosis 
of the tubes and ovaries with an exactitude unknown before the era 
of gynecological surgery. 

The conclusion which receives practically unanimous support is, 
that the gonococcus is by fa?' the most frequent cause of purulent sal- 
pingitis. 

AVertheim, who was among the first to publish any considerable 
number of exactly observed cases from the bacteriological standpoint. 



±$6 A TEXT-BOOK OF GYNECOLOGY 

found that out of 24 cases, the products of inflammation were sterile in 
6; the gonococcus was found in 16; in 1 case the streptococcus was 
found, and in 1, the pus contained a bacterium which he could not 
identify. Wertheim, like most observers, found that the gonococcus 
held the first place as the producer of pyosalpinx, and that other bac- 
teria were the agents only occasionally. He did not see reason to 
believe that the gonococcus prepared the way for secondary invasion 
by pyogenic organisms. As a rule, when the gonococcus is present no 
other bacteria are found. 

Menge's results in his first series of cases in which the Fallopian 
tubes were the seat of inflammation, were much the same as Wert- 
heim's. The gonococcus was the most common cause of the dis- 
ease, but the streptococcus and staphylococcus were occasionally found, 
and, in a very few cases, the Diplococcus pneumonice and the Bacillus 
tuberculosis. In the great majority of cases, the pus in pyosalpinx 
sacs was sterile, and a mixed infection was found to exist in the 
tubes only when they were adherent to other viscera. Adhesion to the 
intestine owing to bacterial inflammation appears to lead to the pas- 
sage of bacteria by softening of the tissues, or by actual communication 
through an orifice formed by destruction of tissues. The other, more 
ordinary, ways in which bacteria gain access are well known. They are 
chiefly by extension of endometritis of bacterial origin upward, or by 
invasion from above, usually by the tubercle bacillus. 

The war of words and opinions regarding " mixed infection " has 
been waged chiefly around pyosalpinx and the relations of the gono- 
coccus to other pyogenic organisms. It is agreed that the gonococcus 
does not incline toward symbiosis, but there can be no doubt that it is 
found occasionally in company with saprophytes and pathogenic organ- 
isms. The discussion has some bearings on practical gynecology, e. g., 
there can be no doubt that gonorrhoea may extend to Fallopian tubes 
already invaded by the slowly acting Bacillus tuberculosis; and the 
clinical facts, as well as bacteriological investigations, show that an 
acute puerperal endometritis, primarily due to the streptococcous infec- 
tion, may be influenced for the worse by the spread of gonococcous in- 
fection from the cervix. Isolated observations like that of Kronig, 
in which a gonorrhceal endometritis was cured through a puerperal 
infection by the streptococcus, and a vulvo-vaginitis by an attack of 
erysipelas in the neighbourhood of the parts, are as yet mere riddles 
with no place in any ordered set of well-supported opinions. Upon 
the whole, however, it may be confidently alleged that the subject of 
" mixed infection " is of interest almost entirely for the bacteriologist 
as distinguished from the gynecologist. 

The bacteriology of chronic salpingitis is of considerable interest. In 
cases operated upon, the tissues are often so much hypertrophied as to 
give the impression, at the time of pre-operation diagnosis, that a 
tumour, or even a cystic tumour, exists. The disease is usually of 
bacterial origin, often set up by the gonococcus, and, like endometritis, 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES ±87 

carrying infiltration and hypertrophy in its train; yet examination of 
the secretion and the tissues in chronic salpingitis hardly ever shows 
the presence of bacteria. 

With regard to purulent salpingitis with or without pyosalpinx for- 
mation, Menge's examinations and his results appear to state the whole 
case. His material consisted of the tubes from 122 cases of purulent 
salpingitis, to part of which reference has already been made. The 
secretion and the tissues of the tubes were examined, and cultivation 
experiments were carried out on a large scale. Shortly stated, the 
results were the following: 

In 122 cases, the contents of the tubes were free from bacteria 75 
times; they contained bacteria 47 times. In 28 cases, the gonococcus 
was found alone; in 9, the tubercle bacillus alone; once, a pyogenic 
staphylococcus alone; once, the colon bacillus alone; once, an anaerobic 
diplococcus alone. In 47 cases, then, in which bacteria were dis- 
covered, the culture was pure in 44 and mixed in 3. The presence of 
the gonococcus was ascertained partly by cultivation, and partly by 
microscopic examination, identifying the organism by the use of Gram's 
method. 

Menge gives numerous details of anatomical changes which are of 
interest from other than the bacteriological point of view. One ob- 
servation will be borne out by all who have had any considerable 
experience in the surgery of the parts, that it is impossible during 
operation to distinguish a pyosalpinx due to tubercle from one due 
to other causes. The discussion of primary and secondary tubercle 
of the female sexual organs in general, and of the tubes in particular, 
hardly belongs to the present subject. It is, however, a striking re- 
sult of bacteriological examination of cases actually operated upon for 
tubal disease, that nearly 10 per cent were found to depend upon the 
tubercle bacillus alone for the anatomical and other changes which 
gave rise to the symptoms. The tubercle bacillus appears, therefore, 
to play a more important part as a parasite of the tubes than the 
streptococcus and staphylococcus. The Bacterium coli commune and 
the anaerobic pathogenic bacteria are still less important. 

Perhaps, says Sinclair, sufficient attention has not been called to 
the fact that, in the great majority of cases of pyosalpinx, the secretion 
and tissues of the walls are found to be germ-free. This must imply 
that the bacteria have died out and that the pus is consequently sterile. 
It is to this fact, almost certainly, that we owe the comparative innocu- 
ousness of pus spilled into the pelvic cavity during operations on the 
pus tubes. It is probably in these obsolete cases, when no secondary 
invasion has taken place, that the symptom of fever does not exist. 
The bacteria have ceased to produce toxines. But this subject, lying 
between bacteriology and clinical gynecology, is still wrapped in 
mystery. 

The relations of infections to inflammations of the tubes are demon- 
strable. 



488 A TEXT-BOOK OF GYNECOLOGY 

Infections of the Fallopian tubes result in inflammation of those 
structures. In the earlier classification of inflammatory diseases of 
the oviducts, the gross, or macroscopic appearance, of the tubal en- 
largements, together with their contents, was taken as the guide for 
nomenclature. Thus the terms hydrosalpinx and pyosalpinx signify, in 
the one instance a watery or dropsical, and in the other a purulent, col- 
lection within the tube, without regard to the causation or pathology of 
the disease. 

This classification still prevails, and quite justly so, for laboratory 
methods have not as yet led to a more accurate or specific nosology 
capable of being successfully adapted to clinical diagnosis. 

Without question, the classification of diseases according to their 
etiology would be preferable, on account of its greater scientific accu- 
racy, but, so far, neither a careful bacteriological examination, nor 
microscopical sections, are sufficient to reveal the primary infecting or 
exciting agent in a majority of cases. 

Tuberculosis is an exception to this rule, for its microscopical 
lesions are so characteristic as to be quite pathognomonic; but even 
this disease is frequently not recognised clinically at the time of 
operation. (See Tuberculosis of the Fallopian Tubes.) Gonococcous 
and streptococcous infections are likewise susceptible, although in a 
less definite degree, of individual study; but even these micro-organ- 
isms, while exercising a dominant and determining influence over the 
course of subsequent morbid events, ordinarily occur in company with 
other pathogenic bacteria. The closer study of the causes of inflam- 
mation in recent years, says Clark, has established the fact that it 
is never an idiopathic process, for it can not originate de novo. Of late, 
he adds, it has also been conclusively demonstrated that the mechanical 
and chemical causes (exclusive of bacterial toxines) seldom play a 
causative role, and that the prime factors in the production of sur- 
gical inflammations are of bacterial origin. To classify accurately 
inflammatory diseases according to the specific organism which pro- 
duced them, would be a scientific ideal; but as this, with the exceptions 
already noted, is not at present practicable, the older nomenclature to 
which we have become accustomed through long usage should be re- 
tained, until after the discovery of more positive means by which the 
different varieties of inflammation, classified according to their causa- 
tion, may be further distingushed from each other. Concerning the 
significance of names in these various conditions, there has been con- 
siderable discussion, but as this is not of great moment, for the obvious 
reasons just pointed out, the usual terms will be employed; when 
necessary, the newer terms will be indicated as synonyms in the con- 
sideration of the general morbid changes that are induced. In the 
present state of our knowledge, it is best to consider infections of the 
Fallopian tubes from (a) the standpoint of morbid histology, and, (b) as 
far as possible, from the standpoint of the individual infectious 
element. 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 489 

Catarrhal Salpingitis (Salpingitis Catarrhal is). — Before taking up 
the morbid conditions of the Fallopian tubes, it may be well to recall 
quite briefly the essential points in their normal anatomy. As each 
tube emerges from the cornu uteri it is of exceedingly small calibre, 
its lumen barely admitting a fine bristle. From this point (ostium 
uterinum) it continues narrow for at least one third of its length, then 
gradually widens into a trumpet-shaped termination which again con- 
tracts somewhat at the abdominal opening (ostium abdominale). Nor- 
mally, the tube runs in almost a straight, course outward for half its 
length, then curves gently downward and dips into the pelvic cavity 
posteriorly to the broad ligament. Its mesentery is formed by two folds 
of the broad ligament within which it is situated. The three layers 
of the tube consist of the enveloping peritoneum, muscle (longitudinal 
and circular), and mucosa. As the mucosa is the portion of the tube 
primarily affected in endosalpingitis, the earliest stage of salpingitis, 
a more minute consideration of its finer histology will not be out of 
place. 

This coat is continuous with the lining membrane of the uterus, 
but, unlike it, has no glands, although the depressions between the 
folds are so strikingly similar as to have caused Hennig, and later 
Bland Sutton, to describe them as true adenoid structures. The gen- 
eral consensus of opinion among the best histologists of the present 
time is against this acceptation, and the mucosa may therefore be con- 
sidered as a simple nonglandular tissue. The interstitial, or uterine, 
portion of the tube resembles in shape the letter H, and is lined by 
one layer of columnar ciliated epithelium; in the extra-uterine part of 
the tube, the mucosa assumes a rugous appearance, being thrown up 
into exquisite villous or coral-like projections. The connective-tissue 
stroma contains delicate vascular twigs which run out at right .angles 
from the circular blood vessels of the tube, and terminate as a rich 
anastomosis beneath the epithelium. As the abdominal end of the tube 
is approached, the mucosa is more and more thrown into duplicatures 
until it terminates in the fimbriated extremities. A sharp line of de- 
marcation indicates the line of union between the mucosa and peri- 
toneum at the tips of the fimbriae. 

Morbid Histology of Acute Salpingitis. — With this brief resume of 
the essential points in the normal histology of the tube, we may take 
up, with a clearer understanding, the various inflammatory changes 
that occur in that structure, all of which, regardless of their mode of 
origin, start first as a simple salpingitis. This condition may very 
quickly merge into either the purulent or the hemorrhagic type, but so 
far as the primary pathologic phenomena are concerned, the classic 
signs of inflammation — color, rubor, dolor, and tumor — are present, and 
accompanying them are the vascular injection, the transmigration of 
the leucocytes, the increase in round-celled infiltration, and the swell- 
ing of the epithelium, all characteristic histological changes in acute 
inflammation. In the acute stage of inflammation, the normal secre- 



490 A TEXT-BOOK OF GYNECOLOGY 

tion of the tube is only slightly changed. Its consistence is at first 
fluid, later mucoid, the colour being transparent whitish, milky, or 
reddish, according as it is mixed with desquamated epithelium and 
leucocytes or with red blood cells. One of the most striking macro- 
scopical changes in the acute process is the marked congestion of the 
blood vessels, which are greatly reddened and injected and present 
a riblike appearance beneath the peritoneal covering of the tube. With 
the increase in length and thickness of the tube through these morbid 
changes, the tube usually becomes kinked and twisted upon itself, be- 
cause the mesosalpinx maintains, without any relaxation, its normal 
relationship to the tubes; consequently the latter, as it becomes length- 
ened and enlarged, is thrown into a distorted shape. The fimbriated 
end of the tube, being the seat of terminal vessels, is greatly congested, 
of a bluish-red colour (cockscomb colour), and a stringy, glairy mucus 
is either seen escaping, or may be expressed from, the abdominal orifice. 

From the very beginning of the inflammatory process, the secretion 
of the tube may assume a purulent character. Menge asserts that this 
is the rule in gonococcous infection, and yet Doderlein, to a certain 
extent, negatives this statement by the report of a case of double gonor- 
rhoea! tubal inflammation in which myriads of gonococci were found; 
on one side there was a pyosalpinx, while on the other, only a simple 
tubal catarrh had occurred. 

The mucosa is greatly increased in thickness, both on account of 
the hypertrophy of its constituent cells, and because of the vascular 
congestion of the villi. At this stage, a transverse section of the tube 
presents a rosettelike appearance, the mucosa projecting rather promi- 
nently over the peritoneal edges. In the acute stage of the inflamma- 
tion, the morbid changes may be confined entirely to the epithelial 
lining, and the immediately underlying connective-tissue stroma, 
whence the term endosalpingitis. 

So long as the inflammatory condition is strictly limited to the 
mucosa, the outward appearance of the tube, with the exception of 
the vascular injection and reddening, presents no other changes. In- 
deed, in the acute stage, especially when there is no increase in the 
tubal secretion, the appearances are strikingly like those of the tube 
in its period of normal congestion during the menstrual flux. 

Notwithstanding a considerable increase in the secretion of the 
tube, due to the local irritation of the infectious agent, the tubal 
epithelium remains intact much more frequently than would be sup- 
posed. The underlying connective-tissue stroma, and not the epithe- 
lium, is the chief seat of the initial inflammatory changes in acute 
catarrhal salpingitis. 

On section, the mucous membrane presents many folds and duplica- 
tures which form, through contact of their free ends, baylike or loculate 
spaces. The stroma cells are much richer in nuclei and the blood 
vessels are greatly widened, and show considerable transmigration of 
polynuclear leucocytes. 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 491 

Throughout the stroma, in a section by Whitacre, a variable amount 
of round-celled infiltration with beginning suppuration is observed 
(Fig. 210), depending upon the nature and activity of the local infec- 
tion. In isolated areas, minute extravasations of blood are seen. Not- 
withstanding a local irritation sufficient to incite these changes, the 
epithelial layer usually remains intact and does not even shed its 




Fig. 210. — " Throughout the stroma, in a section by Whitacre, a variable amount of round- 
celled infiltration with beginning suppuration is observed." — Clark. 

cilia, although the cells appear congested and swollen. From this stage 
on, the course and termination of the inflammation depends upon a 
number of conditions, such as the variety of infectious organisms, the 
strength of their virulence, and the local resistance of the tissue. Thus, 
there is occasionally observed a loss of the epithelium and complete 
replacement of the mucosa by a cylinder of pus cells (Fig. 211). 

If resolution does not occur in the acute stage before detailed, the 
inflammatory process tends to become chronic, when the extent and 
general characteristics of the pathologic lesions may become most 
diversified. 

Morbid Histology of Chronic Salpingitis (Salpingitis chronica). — 
With the continued action of the irritating agent, be it the primary 
infectious micro-organism or the toxines generated by it, the acute 
inflammatory stage merges into a chronic condition, and a marked 



492 



A TEXT-BOOK OF GYNECOLOGY 



involvement of the muscular portion of the tube occurs. The ser- 
pentine course of the tube becomes more pronounced and sharp twists 
and kinks result. The tube assumes a more bluish or congested appear- 
ance, and many vessels, which previously appeared as capillaries, be- 
come quite prominent. Through the sharp kinking of the tube, micro- 




Fig. 21] (Whitacee). — " Thus, there is occasionally observed a loss of the epithelium and 
complete replacement of the mucosa by a cylinder of pus cells.'" — Clark (page 491). 



scopical sections not infrequently show two or more views of the tubal 
lumen, cut transversely or obliquely. As in all chronic inflammations, 
there is an excessive formation of new connective tissue, which renders 
the tube stiffer and much less flexible than normal. 

The extravasations of blood, which are microscopical in the acute 
stage, may frequently become so marked as to be visible to the naked 
eye as bluish-red spots. Through hypertrophy and hyperplasia of the 
connective tissue and muscular portions of the tube, its wall may reach 
a thickness of 2 centimetres, or even more, in long-standing cases, as 
a result of the continuous irritation and destruction of the tubal epi- 
thelium; the club-ended villous projections of the mucosa adhere to- 
gether, which not only decreases the primitive lumen of the tube, but 
gives it, even on macroscopical examination, a loculate appearance. 
Notwithstanding the fact that this condition appears most frequently 
in the isthmiac portion of the tube, a complete atresia seldom occurs. 
For instance, Reymond found it only once in 94 cases. 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 493 

Sooner or later in the course of the chronic process, plastic lymph 
is thrown out about the tube, which organizes and forms adhesions of 
varying density between the angles of the distorted tube, and between 
the tube and neighbouring viscera. The most frequent and important 
changes effected by these adhesions is the closure of the fimbriated end 
of the tube (see Hydrosalpinx and Pyosalpinx). In the course of this 
atretic process, the abdominal end of the tube may gradually be nar- 
rowed until an opening not larger than a robin's quill remains. Through 
this gradual narrowing, the secretions may be more or less hemmed in, 
with now and then an intermittent discharge into the pelvis, giving rise 
in some cases to an extensive pelvic peritonitis. 

The narrowing of the ostium abdominale may occur, either through 
the gradual adhesions of the peritoneal edges of the fimbria?, or, as is 
not infrequently, but in fact, is usually, the case, the fimbriae become 
invaginated within the tube, and are then incarcerated. 

The small round-celled infiltration which at times occurs beneath 
the mucosa in the acute stage becomes generalized in the chronic pro- 
cess, until, as seen in a section by Whitacre, the entire tubal wall may 
become involved (Fig. 212). From delicate villous termini the folds 
of the mucosa are transformed into rounded fusiform ends filling up 
the lumen of the tube and lying in close contact with each other. 
On account of this contact the epithelium becomes destroyed, and the 
projections adhere together and establish isolated loculi or diverticula. 
These spaces may be gradually obliterated through a typical granula- 
tion process, or the epithelium may remain intact, and, through the 
accumulation of a catarrhal secretion, be transformed into larger cystic 
cavities; or from a ciliated cylindrical type the epithelium may undergo 
retrograde change until it assumes a flattened or endothelial-like ap- 
pearance. 

Through the projection of the fusiform villi into the tubal lumen, 
adhesions may take place between opposing ends and thus establish 
connective tissue bridges from one part of the tube to another. The 
occurrence of the glandlike space has further strengthened Hennig 
and Bland Sutton in their belief in the true adenoid nature of these 
structures. As stated in preceding pages, this theory has found but 
few supporters, for the adventitious way in which these spaces are 
formed becomes too manifest on critical examination. 

In view of the fact that these spaces are the unmistakable products 
of a pathologic process, Martin prefers the term salpingitis pseudofol- 
licularis to salpingitis follicularis as employed by some writers. In the 
chronic stage the tubal secretion may var}^, just as in the acute form, 
from a transparent catarrhal to a purulent character. 

Upon the nature of the secretion depends the nomenclature. The 
usual terms employed in describing the varieties of chronic salpingitis 
are catarrhal, hemorrhagic, and purulent. 

The hemorrhagic salpingitis (Salpingitis Jicemorrhagica), so far as its 
histologic characteristics are concerned, presents no essential variation 



494 



A TEXT-BOOK OP GYNECOLOGY 



from the foregoing description further than that induced through the 
deposition of blood pigment in the areas of extravasation and upon the 
inner walls of the tube. 

The tubal secretion is of a reddish or chocolate-brown colour, due 
to its mixture with red blood corpuscles in various stages of disintegra- 




Fia. 212. — " The small round-celled infiltration which at times occurs beneath the mucosa 
in the acute stage becomes generalized in the chronic process, until, as seen in a section 
by Whitacre, the entire tubal wall may become involved." — Clark (page 493). 

tion. Polynuclear leucocytes crowded with blood pigment are seen 
in various parts of the tissues, and are especially numerous around the 
ecchymotic areas. 

In chronic purulent salpingitis the tubal secretion consists largely 
of pus, varying in appearance from a flocculent sero-purulent character 
to a thick yellowish or greenish colour. If, as a result of a severe 
infection, purulent salpingitis sets in at the very beginning without 
an appreciable catarrhal change, the local inflammatory changes be- 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 495 

come most pronounced, consisting in an excessive transmigration of 
leucocytes, a rapid round-celled infiltration, and a rapidly increasing 
oedema of the mucosa. Through these hypertrophic changes, the tube 
assumes a size much greater than the normal. Martin has attempted 
to establish a differentiation through microscopic examination between 
the acute septic salpingitis and the acute gonorrheal salpingitis. 

According to our view, unless the infectious micro-organism is rec- 
ognised either through cultures or through cover-glass preparations, 
we do not believe this differentiation through a simple histological 
examination is possible except in the hands of an expert microscopist, 
and even then the results must be viewed with considerable scepticism. 

Through the closure of the ostium abdominale, the tube becomes 
more or less distended, and, according to the nature of its secretion, is 
called a hydrosalpinx, hematosalpinx, or pyosalpinx. 

Hydrosalpinx {Hydrops tubarum, Sactosalpinx) is a pathologic col- 
lection of serous fluid within the Fallopian tube due to a partial or 
complete stricture in some part of the tube. 

While a pathologic atresia may occur at any point in the tube, the 
usual seat is at the fimbriated end. In rare cases, more than one 
stricture may take place, which divides a simple hydrosalpinx into two 
or more chambers. 

According to Rokitansky, the occlusion of the fimbriated end is due 
to the adhesion of the peritoneal surfaces of the fimbriae, which become 
inverted within the tube. Klob offers a similar explanation and attrib- 
utes the adhesions to a tubal catarrh, perisalpingitis, or pelviperitonitis. 

According to Klebs, atrophy of the fimbria? may result from a local- 
ized inflammation leading to an inversion of the fimbriae and a filling 
in of the ostium abdominale with scar tissue. While these strictures 
of the tube may result, in rare instances, from other than inflammatory 
causes, as, for instance, the dropsical accumulation in the tube in cer- 
tain cases of myoma, nevertheless, the chief inciting factor is un- 
doubtedly a perisalpingitis. Whether the inflammatory condition is 
always of bacterial origin, is as yet an open question. Menge and 
others have, for instance, described numerous cases in which the occlu- 
sion occurred through a sterile process, such as the chemical irritation 
of hemorrhagic accumulations, and from the mechanical congestion 
due to the pressure of tumours, etc. These cases, however, are com- 
paratively rare, and, as a rule, the first cause may be accepted as the 
chief one. 

While it is generally conceded that hydrosalpinx is sui generis a 
dropsical accumulation, yet such eminent authorities as Zweifel and 
Bland Sutton believe that it may result from the resolution of a pyo- 
salpinx, the purulent matter undergoing a transformation into an 
aqueous accumulation. 

Menge, Ivleinhaus, and others, as the result of careful observation, 
state with positive assurance that such a retrograde metamorphosis 
is not possible, for they say that, although pus may become thick and 



496 A TEXT-BOOK OF GYNECOLOGY 

inspissated, it never undergoes liquefaction, and also that the his- 
tological changes in hydrosalpinx are radically different from those 
observed in pyosalpinx. Upon the basis of Clark's observations an 
unqualified support to the latter opinion may be given. 

As a general rule, hydrosalpinx is attributable to puerperal rather 
than to gonorrheal infection. Menge, for instance, holds very strongly 
to the belief that the gonococcus is a pus-producer, that, consequently, 
a purulent salpingitis or pyosalpinx is usually produced by it, and that 
only in rare instances does hydrosalpinx result from this micro-organ- 
ism, and then only as a secondary process. In explaining the latter 
statement, he says that the primary gonorrheal salpingitis may have 
reached its climax and be undergoing resolution when, as a result of a 
secondary pelvic peritonitis, the ostium abdominale may become oc- 
cluded with a simple hydrosalpinx as a sequel. 

Yon Eosthorn maintains with forcible argument that hydrosalpinx 
is always induced by a pelvic peritonitis. He says that streptococci or 
staphylococci gain entrance to the tube, and, because of attenuated 
virulence, only a simple catarrhal salpingitis is inaugurated, and that 
later, through continuity of structure, the pelvic peritoneum becomes 
involved and the tube is thus sealed by adhesions. Coincidently with 
this occlusion, the secretion of the tube begins to accumulate, first 
distending the abdominal end, then progressively extending toward 
the isthmiac, or uterine, extremity of the tube. Quite naturally the dis- 
tortion decreases toward the uterus on account of the greater resistance 
offered by the tube. 

The escape of fluid is prevented or greatly retarded through ad- 
hesions, organic occlusion, mechanical torsion, or kinks at the uterine 
juncture of the tube. As stated under the head of Salpingitis, an 
actual closure of the lumen of the isthmiac portion of the tube through 
inflammatory changes is comparatively rare. With the increase in the 
accumulation of fluid within the tube, its wall undergoes a gradual 
thinning, and, although a marked pressure atrophy may ultimately take 
place, the visible landmarks of the longitudinal folds of the mucosa 
will appear as ridges running direct from the vestibular to the isthmiac 
extremity of the tube. 

Upon the degree of distention depends the variation in the mor- 
phology, the size ranging from that of a lead pencil, with more or less 
conformation to the normal undulations of the tube, to a very large fusi- 
form tumour with a smooth glistening exterior. As the tube is gradu- 
ally transformed from its normal shape it may assume a sausagelike, 
serpentine, or what is more usual, a retort or pipe shape. In rare 
instances, the tube may reach very large dimensions, and the morpho- 
logic characteristics may be so obscured as to render its identification 
very difficult on account of the close resemblance to a tubo-ovarian, 
ovarian, or parovarian cyst. Even in cases of moderate distention, 
the muscular and connective-tissue layers may become so attenuated as 
to allow the contents of the tube to be seen through its transparent wall. 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 497 

The tubal secretion may be of a clear limpid, a yellowish lemon, or a 
slightly blood-tinged colour, and its formed elements may consist of 
leucocytes, epithelium, red blood cells, and sometimes cholesterine 
crystals. To the latter, Bland Sutton ascribes the greenish colour 
occasionally noted in the fluid. 

With the progressive increase in the size of the tube, the mucosa 
loses its coral-like or villous, appearance, becomes greatly stretched, and 
may undergo such complete atrophy as to leave onlv the small ridges 
before described, or, as is seen in some cases only, small blunt teatlike 
eminences. 

Of the mucosa the epithelium alone remains, and this is usually 
transformed into a cuboidal or flattened variety; in the deep angles and 
protected areas it may, however, still maintain its cylindrical character, 
and even the cilia may remain intact. 

As a unique and rare production, bonelike or calcareous plates are 
found in the walls of the tubes, or, as illustrated by Cullems case, the 
tube may contain a calculus. 

Hydrosalpinx does not, as a rule, reach a large size, although cases 
are reported in which the contents measured a litre or more. 

With regard to the comparative frequency of single or double 
hydrosalpinx, it is usually stated that the double form is the more 
common. To the contrary, however, C'ullen states that in a series of 
27 cases, he found IT unilateral while the remainder were bilateral. 

Types of Hydrosalpinx. — Certain deviations in morphology from 
the simple form just described constitute special types of hydrosalpinx. 
Occlusion of the tube in salpingitis pseudofollicularis. with its sub- 
sequent enlargement, constitutes hydrosalpinx pseudofollicularis. In 
this condition the tube rarely reaches such a large size as the simple 
form, from purely mechanical reasons, for it is self-evident that a 
cavity divided into numerous loculi can not distend, on account of 
increased resistance, with the same facility as a unilocular cavity. 

Cross sections of the tube present a spongelike or irregular 
punched-out appearance, the larger cavities being lined with cuboidal, 
the smaller with simple cylindrical or ciliated epithelium. In some 
spaces, desquamated epithelia are seen. 

As a special variety, named, not because of its histological deviation 
from the simple variety, but on account of its intermittent discharge 
of fluid into the uterus, is the hydrops tube? profluens. In these cases 
the tube may reach a very large size before the sphincterlike action at 
the uterine cornu is overcome, when a profuse serous flux is noticed 
by the patient. This is a comparatively rare condition, only isolated 
instances having been reported from even the largest clinics. 

This peculiar intermittent action of the tube is attributed to sev- 
eral causes. According to Landau, the muscular walls at the uterine 
juncture are greatly hypertrophied. and only when this constriction is 
overcome by the vis a tergo of the serous accumulation is the periodical 
flow inaugurated. 
33 



498 



A TEXT-BOOK OF GYNECOLOGY 



Other investigators have attributed this condition to a stricture of 
the tube which, like the kinked garden hose, is only overcome by 
the gradual increase in pressure behind the point of constriction. 

The last variety of hydrosalpinx, known as tubo-ovarian cyst (Fig. 
213), is a pathologic condition in which the hydrops tubae is associated, 
by organic union, with a cystic condition of the ovary, the fluid from 
one cavity mingling with that of the other. 

These aqueous tumours vary from a very small to a very large size, 
reaching in some instances a diameter equivalent to that of a child's 
head. With a free communication between two secreting cavities, such 
as one finds in these cases, it is quite natural for the cystic tumour to 
reach much larger dimensions than the simple hydrosalpinx. 

The Fallopian tube is situated upon the upper surface of the tumour 
and usually appears as a large club-shaped or retort-shaped body, which 




Fig. 213.—" The variety of hydrosalpinx known as tubo-ovarian cyst.' 1 — Claek. 



is fused at its fimbriated extremity onto the surface of the ovary by 
adhesions of more or less density, depending upon the chronicity of the 
inflammatory process. 

The communication between the cystic portion of the ovary and 
the tube may be established, either by the primary adhesion of the 
spread-out fimbriae upon the surface of the cyst with a subsequent rup- 
ture into the tube, or the free fimbriae may become incarcerated within 
the ruptured opening of a cystic Graafian follicle or other ovarian cyst. 
In general appearance, the tubal portion of this combined tumour does 
not differ from the usual hydrosalpinx, while the ovarian portion con- 
forms to the usual classification of the simple unilocular, multilocular, 
or glandular cysts. 

Where the adhesions are quite dense and the tube and ovary are 
fused together in a very close organic mass, it may be difficult or 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 499 

impossible to recognise macroscopically the loeuli which originate in 
the ovary from those of the tube. In such instances, however, a dis- 
tinction may be made microscopically, through the recognition of the 
characteristic ovarian stroma and constituent cells of the Graafian fol- 
licle. 

Hematosalpinx (Sactosalpinx hemorrhagica) is a collection of blood 
within an occluded tube, similar to the serous collection in a hydro- 
salpinx. Until quite recently all hemorrhagic tubal collections have 
been placed under this classification. Veit, however, has shown that 
this is an error, as the hemorrhage incident to a tubal pregnancy or 
to a malignant growth is merely an accidental product, and should, 
therefore, not be given this misleading name. 

Hematosalpinx is produced through sharp kinks and torsion of the 
tube, thrombosis of the tubal vessels, and from simple hemorrhage into 
a hydrosalpinx. 

Less common causes are acquired or congenital atresia of the uterus 
or vagina, traumatisms of the inner genitalia, and the injuries of 
severe labours. Although the majority of cases may be attributed to 
some one of these easily recognised causes, there is still a considerable 
number of cases in which the minutest history and most painstaking 
physical and microscopic examinations have failed to reveal the true 
etiology. Martin ascribes some cases to vicarious menstruation, while 
others attribute this condition to a reflux of menstrual blood from sud- 
den spastic uterine contractions. Sanger asserts that an aseptic accu- 
mulation of blood in the pelvis may induce a localized peritonitis, 
through which the abdominal ostium becomes occluded while the tubal 
hemorrhage is still in action. The pathologic changes observed in 
these cases depend upon the primary cause of the hematosalpinx. 
When the intratubal hemorrhage is induced through a strangulation 
of the tube, the vessels are thrombosed and numerous areas of extrava- 
sation within the tubal wall are found, and in some instances large in- 
farctions may occur. 

The tissues always stain badly and microscopical sections frequently 
show very much obscured histologic characteristics. More or less ex- 
tensive hemorrhagic necroses frequently take place, but are sharply 
limited by the line of strangulation. 

In the simple cases where the blood is either shed from the mucosa 
into a hydrosalpinx, or where it reaches the tube as a reflux from the 
uterus, the histologic picture presents no essential structural devia- 
tions from those observed in hydrosalpinx. The inner wall of the 
tube is covered with a pigmentary deposit and the mucosa may be the 
seat of minute capillary extravasations. Leucocytes laden with blood 
pigment are also found within the vessels and as wandering cells in the 
tissues. 

Pyosalpinx (Sactosalpinx purulenta; suppuration of the tuoe) is a 
purulent collection within the Fallopian tube, which arises as a result 
of occlusion in some part, usually at the ostium abdominale, of an in- 



500 A TEXT-BOOK OF GYNECOLOGY 

flamed tube. Quite naturally, an agent sufficient to induce this secre- 
tion of pus is of a more irritant nature than that found in a simple 
catarrhal process, consequently the inflammatory reaction is usually 
much more marked. The extent of the involvement is variable, and 
the size of the tube and the thickness of its walls depend upon the 
degree of distention. When the quantity of pus is small, the tubal walls 
are usually greatly swollen and the thickness may exceed the normal 
many fold, whereas in a large tense pyosalpinx the opposite condi- 
tion may be noted, just as in a hydrosalpinx. So far as size is con- 
cerned, a pyosalpinx as a rule does not reach that of a hydrosalpinx, 
although instances are recorded in which an enormous abscess has 
developed. 

Upon the intensity and chronicity of the inflammatory process also 
depends the appearance and character of the pyosalpinx, for with the 
long persistence of the infection there is a steady increase in the 
amount of connective tissue, which transforms the tube from a flexible 
to a stiff resistant condition. Notwithstanding the presence of a very 
irritating infectious matter the lining epithelium may remain intact a 
surprisingly long time; but sooner or later it is completely destroyed 
in those areas exposed to the contact of the pus, and is supplanted by 
granulation tissue. 

As a result of the direct extension of the inflammation through the 
wall of the tube or from local infection of the enveloping peritoneum 
by escape of the pus from the ostium abdominale, the tube is usually 
covered with adhesions which bind it to the neighbouring organs. The 
organization of the adhesions often binds the ovary into an indistin- 
guishable mass with the tube, and in such cases abscesses often form 
in the spaces between these organs, or between the intestines and 
tube (perisalpingeal abscess), thus converting the mass into multiple 
suppurating loculi. 

Just as the tubo-ovarian cyst, described in preceding pages, is 
formed, so may these cases be converted into tubo-ovarian abscesses. 
The ovary, however, notwithstanding its close proximity to the tube, 
is very often free from infection, there being only a simple peri- 
oophoritis which does not penetrate beyond the tunica albuginea. 

The contents of a pyosalpinx vary in consistence from a thin yel- 
lowish purulent fluid to a thick inspissated cheesy matter, consisting 
of disorganized pus corpuscles and red blood cells, fibrin, degenerated 
epithelium, and granular detritus. 

As a rule the culture and microscopic evidence of micro-organisms 
give negative results. 

In the earlier stages of the pyosalpinx, granulation tissues may take 
the place of the mucosa and the underlying tissue become richly 
infiltrated with round cells; later, however, the granulations are trans- 
formed into dense scar tissue and ordinary connective tissue. As the 
inflammatory process becomes chronic, the muscular tissue undergoes 
marked atrophy until mere traces only may remain. The vessels be- 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 501 

neath the peritoneum become thick and tortuous, and sooner or later 
show hyaline degeneration. In some cases the tubal wall may become 
quite cedematous. Even in simple cases, isolated spaces, like those in 
salpingitis pseudofollicularis, are seen, which are lined by granulation 
or scar tissue and contain pus. When a typical case of salpingitis 
pseudofollicularis is converted into a pyosalpinx, cross sections of the 
tube show an exaggerated loculated appearance. As a result of simple 
inflammation or from the deposition of lymph which undergoes organi- 
zation, the peritoneum may become very greatly thickened. 

Symptoms and Diagnosis of Salpingitis. — Although we may have 
a morbid process strictly confined to the tube — a salpingitis — we much 
more frequently find that other tissues have been implicated at the 
same time. More especially is this true of the pelvic peritoneum; and 
in many cases, therefore, the symptoms of a salpingitis are largely modi- 
fied by the virulence and extent of the accompanying peritonitis. 

General Considerations. — The symptoms of inflammation of the 
uterine appendages and the pelvic peritoneum vary with the extent and 
character of the infection. The less virulent the infecting agent, 
and the greater the resisting power of the various anatomic structures 
it encounters, the more limited is the extent of the morbid process 
and the less severe its general and local effects upon the organism. 

In primary tubal infections, Nature often prevents the direct exten- 
sion to the other pelvic tissues by sealing the fimbriated end of the 
tube. It is true that the morbid process sometimes, though very 
seldom, makes its way through the walls of the tube, but in such 
cases the battle is prolonged, and the resistance being greater, the other 
tissues of the pelvic cavity are only implicated to a limited extent. 
When the inflammation has been only just severe enough to seal up 
the fimbriated extremity of the tube, the mucous membrane may be 
left in a practically unaltered condition, but the normal secretion 
being poured out dilates the cavity. If this condition is speedily re- 
lieved by the escape of the exudate into the pelvic cavity or into the 
uterus, the symptoms, so far as the tube itself is concerned, may be 
imperceptible. But since the tube is much less sensitive to pain than 
the uterus and ovaries, even when the exudate is localized and retained 
in it, but little disturbance may be caused. For this reason the milder 
catarrhal inflammations, even when acute, may cause symptoms too 
slight to fix the patient's attention definitely upon the diseased part. 
They may, indeed, run their course and disappear without ever having 
been recognised, leaving behind hardly any perceptible trace. So fre- 
quently do these processes escape notice, that it may- be said that in 
an acute or chronic catarrhal salpingitis the symptoms are seldom of 
a prominence sufficient to give rise to the suspicion that any disease is 
present. 

In the cases which present symptoms there is more or less localized 
pain or discomfort, the nature and intensity of which varies within 
wide limits. Thus, sometimes the patient complains rather of a dull 



502 A TEXT-BOOK OP GYNECOLOGY 

aching or burning sensation, which only becomes a real pain when she 
moves about or goes up or down steps, or when local pressure upon 
the parts is exerted by walking, defecation, or the various manipula- 
tions of the examining physician. And yet, despite this, the tube may 
be distended and almost ready to burst (Fig. 220). 

In the so-called colica scortorum the attack is characterized from 
the beginning by sharp colicky pains in the region of the tubes. These 
come on in paroxysms, while in the intervals the patient enjoys com- 
parative comfort. This intercurrent pain is considered by Schauta to 
be characteristic of salpingitis isthmiaca nodosa. In other cases, as has 
been said, the intense pain points rather to extension of the process 
to the peritoneum or the ovaries. 

To a large extent the sufferings of the patient are due to mechanical 
causes. It can be readily seen that greatly dilated and swollen tubes, 
especially when the filling up has been rapid and the tissues have not 
had time to adapt themselves to the stretching, might give rise to 
intense pain, particularly if the pelvic tissues around are inflamed and 
sore. Hence the mechanical symptoms may be numerous. The pres- 
sure or dragging upon the different tissues may give rise to painful 
defecation and micturition, difficulty and pain on standing or moving 
about, together with pressure neuralgias and symptoms referred to the 
digestive tract or the cerebro-spinal system, all of which may be 
reflex in origin. At the time of menstruation, the congestion of the 
ovary, which is often bound down together with the tube by firm adhe- 
sions, resisting its expansion, doubtless accounts for not a little of 
the pain. The great possible variety and intensity of these mechanical 
disturbances should always be kept in mind. Though, as a rule, it 
may be said that marked aggravation of the symptoms with nausea, 
fever, abdominal distention, tenderness, drawing up the thighs, and 
a pinched expression of the face, point to the development of a general 
peritonitis, we may sometimes at operation be agreeably surprised to find 
that the inflammation is localized to one or more parts of the peri- 
toneum, and that the mechanical factors of pressure or traction have 
been sufficient to give rise to indications of the existence of the more 
alarming condition. 

During the monthly period the pathologic congestion is increased, 
so that dysmenorrhea is common. In most cases of tubal disease 
there is usually an increase, rather than a decrease, in the menstrual 
flow, and even menorrhagia may be present. Absent or scanty men- 
struation should make us suspect tuberculosis. Sterility is a common 
symptom in tubal disease, and is due, either to mechanical obstruction 
to the passage of the ovum or spermatozoa, or to the distinctive influ- 
ence exercised upon them by the poisonous material which they en- 
counter in the tube. 

In a large number, one might say in the majority, of cases of pelvic 
disease, a satisfactory diagnosis can only be arrived at after an examina- 
tion under anaesthesia. The relaxation of the abdominal muscles en- 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 503 

ables us to examine more thoroughly, and at the same time does away 
with the necessity of using any violence. Hence the safety of the 
patient is secured, as well as the means of making a more satisfactory 
diagnosis. A thorough evacuation of the bowels and of the bladder 
should always be provided for. Combined internal and external palpa- 
tion is necessary. The right hand being placed over the hypogastrium 
assists the left index finger in the vagina; or the index finger may be 
inserted into the rectum and the thumb into the vagina. In cases of 
adnexal disease it will generally be possible to make out on one or both 
sides a mass, which in most cases proves to be the inflamed tube, or 
this together with other structures implicated, according to the char- 
acter or extent of the process. To decide as to the nature and limits 
of the various component parts of the mass is often difficult or even 
impossible. Again, there are quite a number of conditions which may 
be confused with adnexal inflammation, the principal of these being: 

1. Tumours of the uterus, tubes, broad ligaments, intestines, 
sacrum, and ilium. 

2. Appendicitis. 

3. Intestinal adhesions. 

4. Faecal accumulations. 

5. Extra-uterine pregnancies. 

6. Uterine displacements. 

7. Parametritis. 

8. In rare cases a displaced kidney, spleen, or other abdominal 
viscus, may simulate a pathologic condition of the adnexa. 

A myoma developing lateralward from the uterus may simulate 
in form and location a sactosalpinx. As a rule, however, the former, 
being more closely incorporated with the uterus, causes an enlarge- 
ment of the body. Myomata develop gradually, are frequently pain- 
less, and are characterized by more profuse menorrhagia than is com- 
mon in tubal disease. Again, while the symptoms due to pressure are 
more marked, those indicative of inflammation are absent in uncom- 
plicated myomata. 

In neoplasms of the tubes and broad ligaments, we have an absence 
of a history and of symptoms of infection. Again, new growths are 
less painful, of slower development than the masses resulting from 
adnexal inflammations, and at the same time they are not so likely to 
produce adhesions so early. Only when such do not exist, will the 
recognition of the masses as distinct from the adnexa be possible and 
render the diagnosis certain. 

Ovarian tumours are often distinguished from instances of sacto- 
salpinx only by means of an exploratory incision. The following points 
of distinction, however, should always be remembered: A tumour of 
the ovary is more likely to assume a somewhat globular shape, while a 
sactosalpinx is rather elongated. Again, the sactosalpinx can often be 
made out to be nearer the uterus, and if the ovary can be isolated in 
addition to a tumour between it and the corpus, the diagnosis is ren- 



504 A TEXT-BOOK OF GYNECOLOGY 

dered comparatively easy. Large ovarian tumours can be distinguished 
by their size, but in the case of small parovarian or ovarian cysts and 
solid tumours, when the course of the tube can not be followed from 
the uterus to the ovary, a diagnosis is usually impossible. Sometimes 
a distended tube may be felt above the brim of the pelvis and may 
simulate very closely a suppurating ovarian cystoma. Here, the history 
and examination give us no help toward a diagnosis. 

Appendicitis. — When there exists no tubal disease, the history and 
symptoms coupled with the physical examination will aid us in making 
our diagnosis. Again, the pain of an appendicitis is more often local- 
ized, or at any rate, has a maximum intensity, over McBurney's point, 
while that of adnexal disease is most prominent lower down, in what 
is known as the ovarian region. 

When, however, an appendicitis, as happens not infrequently, com- 
plicates a salpingitis, a diagnosis of the former condition is generally 
made only at operation. 

Intestinal adhesions and intestinal obstruction from pelvic inflamma- 
tion, except when a loop of intestine is adherent to the tubes or broad 
ligaments, can generally be made out by physical examination, espe- 
cially when the tubes are not implicated. In intestinal obstruction, 
the onset is generally more sudden, and the symptoms on the part of 
the bowels are suggestive. 

Fcecal accumulations in the rectum can be made out with the ex- 
amining finger. 

Extra-uterine pregnancy has usually begun in the tube, and we may 
therefore feel what appears to be an inflammatory sactosalpinx. Here,. 
however, we have a history and certain symptoms pointing to preg- 
nancy. Enlargement of both tubes excludes an ectopic pregnancy 
except in those very rare instances in which we have a sactosalpinx on 
one side and a tubal pregnancy on the other. 

Uterine displacements may frequently lead to confusion. A dis- 
placed corpus uteri may often simulate an inflammatory mass, but the 
recognition by means of conjoined palpation and, when necessary, the 
use of the sound, will seldom fail to guide us to a correct diagnosis. 

The diagnosis of parametritis and its relation to adnexal disease 
have been discussed in another place. 

Hematoma. — Here the history will aid us. With a large flow of 
blood into the pelvic cavity from rupture of a tubal gestation or other 
cause, we have generally acute pain, without signs of inflammation, 
but with those of more or less severe internal hemorrhage. Only 
when the hematoma has become infected, will signs of pelvic abscess 
appear. 

Finally, it may be said that, even after we have arrived at a diag- 
nosis of adnexal disease, it will often be impossible to decide absolutely 
whether the tube or ovary or both are implicated. Nor shall we 
always be able to say before operation, in the case of tubal disease, the 
exact condition which exists, or to arrive at the etiological factor, 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 505 

until a bacteriological examination has decided the matter. Suggestive 
information can often be obtained from examination of the vaginal dis- 
charge. 

Having referred to the symptoms and diagnosis of disease of the 
adnexa in general, it will be well to take up the different forms of sal- 
pingitis separately and give somewhat more in detail their distinctive 
characteristics. 

Hydrosalpinx. — When the inflammation has been only sufficient to 
glue the fimbriae together, it is quite possible for the tube to be dis- 
tended with a serous exudate (the natural secretion which is now pent 
up) without giving rise to any symptoms, unless indeed the resulting 
tumour should be of a size sufficient to cause mechanical disturbances. 
But the distended portion of the tube hardly ever exceeds the size 
of an average orange, and the neighbouring parts easily accommodate 
themselves to their slight change in position, especially if it comes 
about gradually. When the process has invaded the serous membrane 
with more virulence, we have, as might be expected, a degree of pain 
corresponding to the grade of inflammation and the number and ex- 
tent of the adhesions. 

Leucorrhceal discharges are common in the majority of pathologic 
conditions affecting the uterus or the adnexa. In a pure catarrhal con- 
dition confined to the tube, the discharge is generally of a whitish char- 
acter. A muco-purulent discharge points rather to inflammation of the 
endometrial lining of the uterine cavity, and is not caused by a localized 
peritonitis. The presence of an endometritis more probably indicates 
a possible purulent salpingitis than a hydrosalpinx. 

As generally happens in any case of pelvic inflammation, men- 
strual disturbance is often present in hydrosalpinx; the flow is gen- 
erally too frequent and is increased in quantity. 

In hydrosalpinx, constitutional symptoms may be entirely absent. 
The temperature is normal or only slightly elevated, the patient may 
have a good appetite and may feel well. She may be able to perform 
her daily duties and live in comfort. At other times, however, exertion 
may bring on pain in the pelvic region on one side or on both. 

Diagnosis. — It would seem that a diagnosis of hydrosalpinx should 
be easily made after a careful physical examination. As a matter of 
fact, this is true in some cases. AThen we find a kidney-shaped 
tumour, generally unilateral, in the position normally occupied by the 
Fallopian tube and near the ovary, we may feel quite certain that we 
have to deal with a salpingitis. Again, since the tube is normally 
divided into compartments, when we find this sausage-shaped tumour 
sacculated, we may conjecture with great probability that we have a 
tube which is distended with fluid, whether it be serum or blood, and 
consequently we may make a diagnosis of hydrosalpinx or hematosal- 
pinx. And yet, even after we have decided that the tumour present 
is part of a distended tube, we shall often remain in doubt as to the 
exact character of its contents. As a rule, however, in hydrosalpinx 



506 A TEXT-BOOK OF GYNECOLOGY 

the walls of the tumour are thin and the mass gives to the finger a 
sense of elasticity, the degree of which is largely dependent upon the 
size of the growth and the consequent thinness of the walls. The 
lack of adhesions is always an important factor, and mobility of the 
tumour is more characteristic of a hydrosalpinx than of a pyosalpinx. 
When, however, the tube is greatly distended, the tumour takes on a 
rounded form and resembles more an ovarian cyst. 

The other principal conditions liable to be confused with a hydro- 
salpinx are small ovarian or parovarian cysts, hematosalpinx, and ex- 
trauterine pregnancy. A typical hydrosalpinx is movable, sausage- 
like, or reniform in shape, and its course can be followed, as it comes 
off from the uterus, in the position occupied normally by the tube. 
The ovarian tumour or cyst is rounded and separated from the body of 
the uterus. A parovarian cyst may be movable, but it is more usually 
of a rounded than of an elongated form. 

Extra-uterine pregnancy is distinguished by the history and by 
various signs pointing to pregnancy. Again, as has been said, sal- 
pingitis causes dysmenorrhea more often than amenorrhoea; and the 
latter, together with enlargement of the breasts and other more or less 
definite symptoms, should always suggest a possible ectopic pregnancy. 
Later, rupture with the classic symptoms of internal hemorrhage makes 
the latter diagnosis certain. With respect to the diagnosis between 
hydrosalpinx, hematosalpinx, and pyosalpinx, more will be said later. 

Hematosalpinx. — Here, instead of a serous fluid, we have a sacto- 
salpinx containing blood. As a rule, the symptomatology and physical 
signs are much the same in both conditions. The tumour is in the 
same position and of the same shape as a hydrosalpinx. 

Hematosalpinx, except as a result of tubal pregnancy, is simply a 
hydrosalpinx into which a hemorrhage has occurred, and naturally 
therefore in its simple form is a rarer condition than hydrosalpinx. 
Various tables are found in text-books showing the important distin- 
guishing points. But, when all has been said, the fact remains that as 
a rule neither the history nor the symptomatology affords a sufficient 
basis for a positive diagnosis between these two closely allied conditions. 

Pyosalpinx. — When a purulent focus exists in either one or both 
tubes the process often extends to the ovaries or the pelvic peritoneum. 
The symptoms vary according to the intensity and extent of the in- 
fective process. In the acute stage, which lasts a week or more, the 
pain is intense. The patient lies in bed with the knees drawn up and 
looks and feels very ill. The pain complained of is sometimes localized, 
but it must be remembered that, without any general peritonitis the 
pain and tenderness may be diffuse and may be referred over the whole 
abdominal region. 

The temperature ranges from 100° to 105° F.; the pulse is rapid, 
100 to 120; when pus is present, the patient frequently complains of 
chills or chilly feelings, and she may also suffer from sweats. The 
abdomen is tense and tender, sometimes sufficiently so to suggest the 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 507 

presence of a general peritonitis, although in reality the process may 
be more or less strictly localized. 

In favourable cases, after a few days the temperature becomes lower, 
although it may still be one or two degrees above normal with remis- 
sions. The pulse rate remains slightly above the normal. In such 
cases the patient may often be able to get about, but every now and 
then she will have a setback and suffer for a few days from high fever 
and pain, after which the temperature falls again. These relapses are 
probably due to the escape of a small amount of pus from the abscess 
with a resulting peritonitis. When a large abscess ruptures suddenly 
a general peritonitis may be set up, and unless prompt operative in- 
tervention occurs, the result is likely to be fatal. 

This recurrence of attacks may go on for years. The patient is 
never well, and at intervals is dangerously ill. Such cases have often 
been cured by removal of the pus sacs. 

In cases of gonorrhoeal salpingitis, we can often obtain a history of 
a sudden attack of vulvitis or vaginitis which has sooner or later been 
followed by abdominal pain. It may, however, be difficult to obtain 
so direct a history from the patient, as it may be months or years before 
she comes to us with symptoms referable to the tubes or pelvic perito- 
neum. Many patients give no history of gonorrhoea, but they may com- 
plain that they have been suffering for some weeks or months from pain 
in the lower part of the abdomen with, perhaps, painful micturition 
and defecation. They may also tell us that they think they have had 
fever, and that at intervals they have had chilly sensations or definite 
rigors. Despite the length of their illness, however, we may find 
them with fair appetites, little or no fever, and, generally speaking, in 
excellent condition except for the local symptoms. 

A streptococcous infection generally dates from a labour, an abor- 
tion, or local treatment. It is usually ushered in with a chill and 
the fever rises rapidly. This continues for some days, and the pinched 
look and anxious expression of the patient show very visibly the 
effects of the absorption of septic material. Abdominal tenderness 
and distention are marked. After the acute stage has passed, the 
patient may get out of bed, but she usually still has a septic tempera- 
ture and hardly ever attains the relative health of the gonorrhceal 
cases. 

Obstinate constipation is sometimes present, usually because the 
patients fear to have a stool on account of the severe pains that are 
excited by the efforts. Occasionally partial or complete obstruction is 
caused by bands of inflammatory tissue stretched across and confining 
the lumen of the bowel (Fig. 214). 

Painful micturition is not likely to be present when the purulent 
process is confined to the tube; often, however, the bladder is pressed 
upon by the inflammatory mass or becomes infected with the specific 
poison (Fig. 215). In the most favourable cases, if not submitted to 
operation, weeks or months elapse before the poison has worn itself 



508 



A TEXT-BOOK OF GYNECOLOGY 



out. Only in rare instances does the patient regain complete health, 
and then, as a rule, only after months of suffering and inconvenience. 
After the disease has become subacute, the symptoms, though less 
severe, are still present, and exacerbations may occur from time to time. 
A persistent suppurative process in the tube or in the pelvic perito- 
neum gives rise to vari- 
ous pains, especially to 
a bearing -down feeling, 
headache, backache, 
often to a chronic puru- 
lent discharge, and some- 
times to painful micturi- 
tion and defecation. A 
gonococcous infection 
often wears itself out in 
this way. 

Exacerbations occur 
with a sudden rise of 
temperature, which in- 
dicates that there is a 
further lighting up of the 
process or that it has ex- 
tended into the perito- 
neum. Sometimes all 
the signs of a general 
peritonitis appear, and 
the prognosis in these 
cases is grave. 

In the diagnosis of 
suppurative processes in 
the tubes the history is 
of great importance. If 
the patient dates her ill- 
ness from an acute attack 
with the symptoms be- 
fore mentioned, begin- 
ning after a labour or an 
abortion, or during the 
course of local treatment to the uterus, a streptococcous infection is 
strongly to be suspected. Some patients will give a clear history of a 
preceding gonorrhoea, while from others, careful questioning will elicit 
an account of an attack of vaginitis which we may safely put down as 
of gonorrheal origin. 

In still other cases, no date can be assigned by the patient to the 
onset of the disease, which has come on insidiously. Leucorrhcea may 
have been noticed for some time, with increasing pain at the menstrual 
period, or perhaps menorrhagia. The patients who are suffering with 




Fig. 214. — " Occasionally partial or complete obstruction 
is caused by bands of inflammatory tissue stretched 
across and confining the lumen of the bowel." — Kobe 
(page 507). 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 509 

a pelvic peritonitis are generally in a much worse condition than those 
in whom the suppurative process is limited to the tubes. But much 
variation may be looked for. Some women, despite the existence of a 
localized suppurative process, look well and robust though they com- 
plain of pain at times; while others are completely broken down, and 




Fig. 215. — " Often the bladder is pressed upon by the inflammatory mass or becomes infected 
with the specific poison." — Robb (page 507). 

show in their faces and in their general behaviour that they are chronic 
invalids. Some are without pain so long as the}^ sit still or lie down, 
but the slightest movement or jarring may evoke severe suffering. 
When the pelvic abscess is situated elsewhere than in the tubes, the 
diagnosis by means of the physical examination taken in conjunction 
with the symptoms of pain, chill, fever, and rapid pulse, is compara- 
tively easy, especially when the attack has followed parturition or 
abortion. "When a mass is felt which bulges out the vault of the vagina 
and is very tender to the touch and fluctuates, we may safely conclude 
that we are dealing with suppuration of the tube or ovary, or both, 
with pelvic peritonitis. When the inflammation has been mainly con- 
fined to the tubes the diagnosis is more difficult, but it will often be 
possible to feel a mass coming off from the side of the uterus and, 
though intimately connected with it, having a mobility of its own. 
On attempting to move the mass we find it possible to do so to a slight 
extent, unless it has been bound down too firmly with peritonitic ad- 
hesions. Sometimes a mass is found on either side of the uterus, and 
in these cases we may be confident that there is tubal or tubo-ovarian 
disease on both sides. It is not always possible to recognise the pres- 
ence of pus by palpation, since fluctuation may not be obtainable owing 



510 



A TEXT-BOOK OF GYNECOLOGY 



to the thickening of the walls of the tube and the dense adhesions. 
Sometimes, however, when on gentle palpation the tumour has ap- 
peared to be solid, by manipulating the external and internal fingers 
so that the tumour is brought between them, a very distinct sensation 
of fluctuation can be obtained. 

Again it must be remembered that in not a few cases of pyosalpinx 
there are only a few drops of pus in the tube. 

In making a diagnosis of pyosalpinx the history is of great assist- 
ance, and it is often also of service in determining the etiology of the 
suppurative process. 

The following data have been given by Kelly to aid in the diagnosis 
between a pyosalpinx of gonorrhceal and one of a streptococcous origin : 

GONORRHCEAL INFECTION STREPTOCOCCOUS INFECTION 

Slow in its onset, often preceded by in- Onset abrupt, following miscarriage, nor- 

flammation of the external genitals mal labour, or topical treatments. 

and urethra. 

Pain localized in one or both ovarian Pain more general and severe in the 

regions. lower abdomen. 

No signs of general peritonitis. Usually signs of peritonitis. 

Suffers more or less constantly, but may Suffers constantly, and usually has a 

have no fever. septic fever. 

Temperature 98.5° to 102° F. (38.9° C). Temperature 101° to 105° F. (38.3° to 

40.5° C). 

Pulse accelerated, but of good quality Pulse feebler and more rapid. 

and volume. 

Attack lasts from five to fifteen days. Attack seldom lasts less than a month, 

and may continue three months or 
more. 

Often presents the appearance of good Anaemic and weak. 

health. 

Gonococci usually found in coverslip prep- Gonococci, not found in the secretions. 

arations from the cervical, urethral, or 

vulvo-vaginal glandular secretions. 

History of marital gonorrhoea. Husband sound. 

Pyosalpinx is sometimes confused with appendicitis and other con- 
ditions to which we have already referred. As points serving to distin- 
guish pyosalpinx from hydrosalpinx, Dudley gives the following: 



Hydrosalpinx 
Systemic disturbance relatively slight. 

Less fever, pain, and adhesions. 
Bursting of the tube and discharge of its 

contents into the abdomen may give 

relief. 
Walls of the tube distended, thin, smooth, 

elastic, and fluctuating. 



Pyosalpinx 

Systemic infection often marked from 
absorption of pus. 

More fever, pain, and adhesions. 

Bursting of the tube and discharge of its 
contents may cause dangerous perito- 
nitis. 

Walls of the tube thick, hard, sometimes 
stony, resistant, nodular, less elastic, 
and less fluctuating. 



INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 511 

Hydrosalpinx Pyosalpinx 

More usually associated with catarrhal More usually associated with purulent 

endometritis. endometritis. 

Thin, overstretched tubal wall easily rup- Walls usually not so easily ruptured. 

tured. 

It may be said that a hydrosalpinx, while often very elastic, on 
acount of the great distention does not give fluctuation. Sometimes 
the wall of a pyosalpinx, instead of being thickened, is as thin as that 
of a hydrosalpinx. Great care should be exercised during the examina- 
tion not to rupture any fluctuating tumour that may be found, as, by 
so doing, the risk is run of infecting the whole peritoneal cavity. In 
some cases a pyosalpinx forms a large tumour projecting above the 
symphysis, or more commonly toward one or other groin just above 
Poupart's ligament. With the history and combined internal and ex- 
ternal examination, the existence of a suppurative process can be deter- 
mined, but often only an operation can decide its exact nature, whether 
it is a suppurating cystoma of the ovary or a pyosalpinx. 

Tuberculous Salpingitis. — In secondary tuberculosis of the adnexa, 
the symptoms are usually masked by those arising from the tuberculous 
process elsewhere in the body. Although the possibility of a primary 
tuberculous process in the tubes should always be borne in mind, ex- 
perience has taught that there is nothing in the symptomatology char- 
acteristic of the condition. Even at the time of operation it has again 
and again escaped detection and has only been discovered later by the 
aid of the microscope. 



CHAPTER XXXIY 

INDIVIDUAL INFECTION'S OF THE FALLOPIAN TUBES 

Infections by: (a) Gronococcus; (b) streptococcus ; (c) Bacillus tuberculosis; (d) Bacil- 
lus coll communis ; (e) pneumococcus ; (/) staphylococcus ; (g) saprophytes ; (h) 
septic vibrion ; (i) actinomyces. 

Individual infections of the Fallopian tubes are, many of them, 
yet in course of preliminary investigation. Those which have been 
determined with reasonable accuracy and which, consequently, will be 
considered, although briefly, in this work, depend upon (a) the gono- 
coccus, (b) the streptococcus, (c) the Bacillus tuberculosis, (d) the Bacil- 
lus coli communis, (e) the pneumococcus, (/) the staphylococcus, (g) the 
saprophytes, (h) the septic vibrion, (i) the actinomyces. 

Gonococcous Infection of the Fallopian Tubes. — Infection by the 
gonococcus of Neisser (see Micrococcus Gonorrhoeae), according to the 
general consensus of competent observers, is responsible for a majority 
of purulent accumulations within the tubes and for those inflamma- 
tory changes which are induced thereby. This infection of the female 
genitalia, more conspicuously than any other, may be designated as 
of the ascending type; by which is meant that an infection beginning 
externally or within the vagina, gradually travels upward, chiefly, if 
not exclusively, by progressive invasion of the mucous surface until 
it reaches the Fallopian tubes. There remain, however, some unex- 
plained facts in connection with this phenomenon: thus, gonococcous 
infection of the vulva and vagina is not uncommon among children (see 
Infections of the External Genital Organs); yet pus tubes are prac- 
tically unknown in childhood. Of course, the immature development 
of the uterus before puberty offers a certain physical barrier to the 
upward extension of this affection in children; but it would seem 
that at least occasional instances would be forthcoming in which the 
obstacle had been overcome. There is a strong probability that in- 
vestigation will establish the fact that the uterine mucosa of childhood 
with its dearth of epithelium is an uncongenial soil for this micro- 
coccus. With the developmental impulses which come at puberty, how- 
ever, these conditions are changed, and there are established a certain 
luxuriance of epithelium and a certain deepening of the utricular folds 
which are favourable to the propagation of the germs of gonorrhoea. 
(See Infections of the Uterus.) 
512 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 51 3 

Gonococci in the Fallopian tubes are found in the pus and upon the 
surface of the mucous membrane. They have been reported as being 
observed in the deeper layers of the tubes, but these observations 
have been seriously questioned by competent observers. Westermark 
was the first to demonstrate the organism in intratubal pus. His ob- 
servations have been confirmed by Orthmann, Zweifel, Witte, Doder- 
lein, Schauta, Morax, and numerous other observers in various coun- 
tries. It is not always demonstrable in this medium. Eeymond reports 
the observations of nine investigators, who have demonstrated the pres- 
ence of gonococcus in tubal pus 78 times in 399 cases. The fact that 
it is not present in the pus of a given case at a given time is not to 
be construed as evidence that it was not the essential element of in- 
fection, for these micro-organisms perish in their own toxines, and 
thus disappear from the pus for the existence of which they are respon- 
sible. Gonorrhoeal pus of recent intratubal origin reveals leucocytes of 
increased size, which contain groups of gonococci and epithelial cells 
also enlarged and inclosing the same micro-organism. A limited num- 
ber of free gonococci are generally observable. Many observers have 
failed to find the gonococci in the mucous membrane in cases in which 
their presence has been demonstrated in the pus. This, as suggested 
by Eeymond, is probably due to defective methods of staining. Gram's 
method is generally employed, but recent investigators have been 
able to demonstrate the presence of the gonococcus by the methylene 
blue and pure tannin method of Mcolle, after failing to find it by 
Gram's method. In a section prepared in this way by Morax there 
are observable, a layer of pus adhering to the mucous surface; 
leucocytes in the stroma of the mucosa; numerous epithelial cells that 
have lost their positions, form, and dimensions, but contain no 
gonococci; and, finally, both leucocytes and detached epithelial cells, 
which do contain gonococci. A distinguishing feature of these 
changes is that the epithelium is not thrown off en bloc, but the cells 
are shed individually. This manner of desquamation is the exact re- 
verse of that which occurs in streptococcous infection. (See Strepto- 
coccous Infection of the Fallopian Tubes). The fimbria? are studded 
with migrated leucocytes; the surface of the epithelium, says Eeymond, 
is covered with a purulent layer, which is composed of a large number 
of leucocytes and detached epithelial cells. It is in this superimposed 
stratum that the gonococci are readily discoverable, not only in the 
epithelial cells and in the leucocytes, but lying quite free between the 
cells. It seems that these micro-organisms but rarely invade the epi- 
thelial cells which remain in situ, while the leucocytes which lie be- 
tween the epithelial cells are likewise but rarely invaded. Competent 
observers have failed to discover the gonococci deeper than the adven- 
titious layer that has just been described, although "Wertheim asserts 
that he has found them in deeper structures. In this infection the 
muscularis is always engorged, its vessels being apparently multiplied 
in number and increased in calibre, while the lymphatics are filled with 
34 



514 A TEXT-BOOK OF GYNECOLOGY 

leucocytes in course of migration to the mucous surface. The gono- 
cocci are not demonstrable in the muscularis, or within the leucocytes 
in that tunic. Wertheinr's statement, cautiously made to the con- 
trary, lacks confirmation, his alleged observation being explained by 
other investigators as due rather to defective methods of staining than 
to the actual detection of the micro-organisms. The inflammatory 
changes induced within the deep layers of the tube, however, and, 
particularly, the infiltration which occurs at the vestibule, are sufficient 
to cause an inflammation of the peritoneum, with resulting exudation 
and occlusion of the distal ostium of the tube. (See Infections of the 
Peritoneum.) Nevertheless, the gonococci themselves have been dem- 
onstrated on the peritoneal surface in these cases, both Cushing and 
Michaelis having reported instances of undoubted accuracy. It is 
probable that the explanation of this circumstance is to be found in 
the escape of the micro-organisms from the lumen of the tube be- 
fore the closure of the vestibule. (See Morbid Histology of Salpin- 
gitis.) 

The route by which the gonococcus travels from the seat of primary 
infection to the tubes, has been a source of speculation, which has, as 
yet, brought forth no definite conclusions. There are those who con- 
tend that it travels by progressive invasion of the mucous surfaces, by 
direct passage through the tissues, and by traversing the circulatory 
systems, respectively. Each of these three hypotheses has its advo- 
cates. That the mucous surfaces from the ostium vaginae to the tubes 
are progressively invaded, seems to rest upon ample testimony. It is 
exceedingly probable from the observations of Camescasse, Eosthorn, 
and others, that, in the presence of a vaginal infection, the uterus is 
invaded in a much larger percentage of cases than was formerly sup- 
posed; while Steinschneider, after finding the gonococcus present in 
the cervix in every one of 34 consecutive cases of vaginal infection, 
concludes that the invasion of the endometrium is a universal incident 
of gonorrhoea in women. While this conclusion is certainly too sweep- 
ing to be justified by the observations upon which it is based, it is 
nevertheless to be looked upon as one of great significance. The be- 
haviour of the gonococcus on the epithelial surfaces indicates that they 
offer to it the avenue of least resistance for its migration; and that, 
once within the uterus, and within the utricular folds of the endo- 
metrium, there is nothing to keep it from extending its invasion to the 
tubal epithelium. 

There seem to be ample grounds for doubting that the gonococcus 
invades the deeper tissues without reference to circulatory media of 
communication. The fact, however, that it does reach the circulation, 
both sanguineous and lymphatic, rests upon indisputable evidence. 
Blumer, Thayer, and Lazear have cultivated it from the blood, while 
Flexner has demonstrated it at autopsy in lesions of ulcerative endo- 
carditis. The latter observer states that the endocarditides associated 
with gonorrhoea, are commonly caused by the gonococcus, and that, in 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 515 

these cases, a general infection with the micro-organism may take place. 
Inflammations of the pleura and pericardium, and suppurative myo- 
carditis, have been caused by it. These facts establish beyond question 
that the gonococcus may invade the blood and be carried by that 
medium to remoter parts of the system. The common clinical phe- 
nomenon of suppuration of the inguinal glands (gonorrheal buboes) 
in cases of acute gonorrhoea, shows the possibility of invasion of the 
lymph channels, while pelvic lymphangeitis, of similar origin, has a 
similar significance. These facts being established, it follows that the 
contention of Eeymond and Magill, that the gonococcus does not travel 
from the seat of primary infection to the tubes through either the 
lymph or the blood channels, is not supported by analogy. If it is 
granted that the blood vessels may be invaded by this micro-organism, 
and that the lymphatics may likewise become the media of infection, 
it would seem that subepithelial structures are liable to invasion 
through these avenues. The controversy between Wertheim, on the one 
hand, and Eeymond, on the other, and between their respective fol- 
lowers, touching this point, can only be settled in the light of further 
direct observations. 

The symptoms of gonococcous infection of the tubes are not specially 
distinctive. The infection may follow either a virulent acute infection 
of the external genitalia, or it may be the result of a primar}^ infec- 
tion, so mild in character as to have escaped attention. The interval 
between a known primary infection and the manifestation of the 
disease in the tube, may be so great that the connection between the 
two may not be recognised. The natural history of the micro-organism 
and its pathogenic characteristics, is such that its activities are inter- 
rupted, and the patient may enjoy periods more or less prolonged of 
symptomatic health. When invasion of the tubes has taken place, how- 
ever, there is generally an initial chill, which may be very slight, fol- 
lowed by an elevation of temperature, which may not go above 100° F.; 
while, on the other hand, these symptoms may be very intense. Pain 
is complained of at the base of each lower quadrant of the abdomen. 
This pain may be either sharp or lancinating, or it may be pulsating 
and may radiate into the lumbar region, or find expression in the 
sacral plexus or along the sciatic nerve. The pain is increased on 
external pressure or by the concussion incident to walking. Bimanual 
examination will reveal foci of tenderness in the neighbourhood of 
one or both Fallopian tubes, which will generally be found large and 
cedematous. These symptoms may be interrupted by a discharge of 
pus, either through the uterus or the intestine, followed by a period 
of apparent cure. Their return, however, is only a matter of time. 
The actual diagnosis of gonococcous infection can be based only upon 
a demonstration of the micro-organism in the pus. (See Diagnosis of 
Inflammatory Diseases of the Uterine Appendages.) 

The treatment of gonococcous infection is given under the head of 
Treatment of Infections of the Fallopian Tubes. 



516 A TEXT-BOOK OF GYNECOLOGY 

Streptococcous Infection of the Fallopian Tubes. — Infection of the 
Fallopian tubes by the Streptococcus pyogenes generally occurs as an 
acute virulent inflammation — although this micro-organism is some- 
times present when least suspected in the more chronic forms of pyo- 
salpinx. Eeymond and Magill, in their masterly contribution upon 
this subject (Annals of Surgery, 1896), state that they found the 
streptococcus in these cases only with difficulty. It would not respond 
to the culture tests made with ordinary media until after it had been 
revitalized, as it were, by successive inoculations. It would seem that 
the diminution in the virulence of the micro-organisms in some of 
these cases, accounts for the chronicity of symptoms following its 
entrance into the tubes. These authors, in a number of their cases, 
were unable to detect the presence of streptococci until after they had 
made repeated observations in cases which would ordinarily have been 
designated as sterile salpingitis. (See Streptococcus Pyogenes.) 

The symptoms of streptococcous infection of the Fallopian tubes are 
to be studied in the light of the fact that, in the chain of morbid events, 
the invasion of the tubes always occurs secondarily to invasion of the 
uterus. While this is true, an equally important fact to be remembered 
is, that invasion of the tubes occurs so promptly after the primary 
infection of the uterus that the symptomatology of the two conditions 
is, in the majority of cases, essentially coincident. It is only in those 
cases in which the micro-organisms seem to have a diminished viru- 
lence, and in which the symptoms of uterine infection have subsided, 
that there are presented any distinct signs of involvement of the Fal- 
lopian tubes; for, in the presence of acute streptococcous infection 
of the uterus with associated involvement of the lymphatics and gen- 
eral engorgement of the pelvic tissues, the condition of the tubes is, 
as a rule, completely masked. The demonstrated existence of strepto- 
coccous infection of the uterus and of the surrounding structures may, 
however, be accepted of itself as a symptom of involvement of the 
tubes. It is true that in a limited number of cases this rule may 
fail, but even then it remains the safer guide for the treatment of 
the case. The constitutional symptoms of this form of infection are, 
in effect, those of similar infection of the uterus. (See Streptococcous 
Infection of the Uterus.) In a few instances the diagnosis may be 
confirmed by palpation of the enlarged tubes by bimanual manipula- 
tion; but it should be remembered that this is a dangerous expedient, 
as even slight manipulation may result in forcing some of the virulent 
pus from the tube into the peritoneum. The use of the aspirating 
needle for diagnostitial purposes in these acute cases is an even more 
dangerous procedure. The fact of a recent puerperal infection, the 
history of streptococcous invasion of the uterus, and the demonstrated 
existence of large tubes, are facts upon which a presumptive diagnosis 
may safely be based. The isolation of the streptococcus by microscopic 
examination and by culture and inoculation experiments, will clear up 
any remaining doubts as to the character of the disease. 



INDIVIDUAL INFECTIONS OF THE FALLOPIAX TUBES 51' 



The pathology of salpingitis of streptococcal! s origin in its general fea- 
tures is not unlike that already given. (See Morbid Histology of Sal- 
pingitis.) The morbid processes established by the streptococcus and 
the behaviour of the micro-organism itself, however, present some 
features that call for special mention. The thorough studies of this 
subject by Reymond and Magill {Ibid.), upon which this chapter is 
largely based, show that the pus from the tubes contains a relatively 
small number of leucocytes, but a great quantity of eliminated de- 
formed epithelial cells, whose perinuclear protoplasm has often been 
lost. There are also present cells from a deeper layer, which seem 
to have fallen from the frame of the fringes. The streptococci are 
rarely in the leucocytes, more frequently in the epithelial cells, but 
most frequently between the cells. A slide mounted with the pus 
of streptococcous salpin- 
gitis from one of Eey- 
mond's cases (Fig. 216) 
shows desquamated epi- 
thelial cells, sometimes 
without their nuclei, 
connective -tissue cells, 
granular fatty degenera- 
tion, and numerous 
streptococci. The mi- 
crobes are sometimes 
strung out in long 
chains, while in other 
cases they appear as dip- 
lococci, or as chains of 
three links, each one 
slightly elongated. 

The mucosa is gen- 
erally found at the be- 
ginning of the affection 
to have undergone but 

slight modification. The epithelial cells are yet in position and 
have retained to an important extent their cilia, the fimbriae alone 
being a little thickened and infiltrated with leucocytes. In re- 
cent infection the streptococci are found in the calibre of the tube. 
while, according to Bumm. the streptococci throng about the epi- 
thelium of the pavilion, although they do not infest the calibre of 
the tube at its uterine third. It is inferred from this that the micro- 
organisms must have travelled over some other highway than that of 
the lumen of the tube itself, to have reached the vestibule. At a 
later period of the salpingitis, if the lumen remains open, the mucosa 
shows lesions of relatively less gravity than are manifested in the 
other tissues. The lymphatic situated in the centre of each fimbria 
is greatly dilated, and contains leucocytes and streptococci. The epi- 




Fig. 216. — "A slide mounted with pus of streptoeoceous 
salpingitis from one of Revmond's cases." — Keed. 



518 



A TEXT-BOOK OF GYNECOLOGY 



thelium in places, while almost intact, is not provided with vibratile 
cilia. At certain points, groups of streptococci are found beneath 
superimposed layers of epithelium, which is occasionally detached en 
bloc, leaving the fimbriae denuded. The tissues underlying this de- 
nuded area are found more or less infiltrated with streptococci. These 
changes in the epithelium explain the presence of the detached epithe- 
lial cells in the pus. It is noticed that in streptococcous infection the 
superficial cell is not attacked by its free surface as in gonorrhceal sal- 
pingitis, but that the invasion comes from the deep surface. This is 
an essential distinguishing point in the pathology of the two infections. 
As a result of this assault upon the epithelial cells from their base- 
ment membrane, they fall in masses, and not singly as is the case in 
the presence of gonococcous infection. This desquamation, say Rey- 
mond and Magill, is so abundant as entirely to fill the calibre of the 
tube with the detached cells, which mass together and can clearly be 
distinguished from the fringes in a section. 

The changes that take place in the terminal branches of the blood 
vessels are difficult to determine, and it is even more difficult to de- 
termine the relation of the streptococci to the blood vessels. The 
changes are, however, found most frequently at the periphery, where 

are sometimes noticed 
thrombi containing 
streptococci; at other 
times the endothelium of 
the vessels is seen to send 
out promontories into 
their lumen, and here 
are found streptococci 
both within and without 
the free passage of the 
vessels. These changes 
are all graphically shown 
in a section of a fimbria 
in streptococcous salpin- 
gitis, by Reymond and 
Magill (Fig. 217). These 
observers find in the re- 
lation of the streptococci 
to the vessels in these 
cases, confirmation of the 
conclusion of Labadie- 
Lagrave to the effect that " upon the blood is imposed the duty 
of destroying and attenuating the streptococcus." The micro-organ- 
ism is found, particularly at the beginning, scattered through the 
cellular tissue of the aileron, and in the subperitoneal tissue also, 
as the adhesion is formed with the tube or the ovary. An abundant 
cellular infiltration is formed beneath the serosa, whose disappear- 




Fig. 217. — " These changes are all graphically shown 
in a section of fimbriae from a case of streptococcous 
salpingitis, by Eeymond and Magill." — Eeed. 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 519 



ance leaves a point still marked by a group of leucocytes mixed with 
streptococci, which are also found in the cellular infiltration pro- 
duced between the muscular sheaths. 

Tuberculosis of the Fallopian tubes (Fig. 218) is the most frequent 
type of tuberculous disease of the female genital tract, and is char- 




Fig. 218. — " Tuberculosis of the Fallopian tubes is the most frequent type of tuberculous 
disease of the female genital tract." — Whitacre. 



520 A TEXT-BOOK OF GYNECOLOGY 

acterized by the formation of miliary tubercles in the walls of the 
tube, by tumour formation, and by a progressive infection of the re- 
mainder of the genital organs. 

A full appreciation of the frequency and clinical importance of 
the condition has only recently been obtained. While the monograph 
of Hegar (1886) did much to bring this about, that of Williams (1892) 
gave the condition a rank of prime importance, by demonstrating a 
very much greater frequency than had ever before been imagined, and 
by showing that a great many tubes, previously removed as adherent 
and inflamed appendages or passed over on the autopsy table without 
notice, were in reality tuberculous. These tubes gave no macroscopic 
appearance of tuberculosis and were called by him cases of " unsus- 
pected genital tuberculosis." This possibility, when associated with 
the fact that excellent results are obtained by the removal of tubes in 
a condition of even advanced degeneration, has made it a leading sub- 
ject in gynecology. 

The method of infection of the tube by the tubercle bacillus forms 
an important, and at the same time a very difficult, question. We 
distinguish a primary and a secondary infection according as the tuber- 
culous process arises primarily in the tube or is the result of an in- 
fection from a primary focus in the lung, intestine, or peritoneum. 
The latter is by far the most frequent mode of infection. 

Hegar has differentiated an ascending and a descending -form of in- 
fection, of which the latter is always a secondary tubal tuberculosis, 
while the former furnishes all the primary cases and may be a second- 
ary tuberculosis. In the ascending type of infection, the tubercle 
bacillus must be mechanically deposited in the vagina or uterus by 
dirty fingers or instruments, from the clothes or the faeces of the 
patien^ who suffers from tuberculous enteritis, by coitus, or from a 
tuberculous ulceration of the vulva or vagina. It is conceded that the 
primary form of infection may be the result of coitus with men suffer- 
ing from a tuberculosis of one or more of their genital organs. This 
belief is supported by these facts: (a) That tuberculosis of the female 
genital organs occurs with greatest frequency between twenty and forty 
years of age; (b) the recognition of the tubercle bacilli in the semen 
of such men (Dewille); (c) the demonstration of tubercle bacilli in 
the apparently sound genital organs of phthisical men (Fernet, Jani); 
and, finally, (d) the demonstration by Schuchardt of tubercle bacilli in 
the urethral secretions of gonorrhoea. 

The method of the transfer of the germs from the vagina to the 
tube without infection of intermediate organs is a point difficult of 
solution. The escape of the intermediate tissues (vagina, cervix, 
uterus) has been very justly compared to the immunity of the nose, 
throat, and larynx, in lung tuberculosis and is explained by their natural 
protective forces. The tube lacks protection and seems to offer a most 
suitable nidus for bacterial development. The spermatozoa, by reason 
of their peculiar motion upward, would seem to be the most natural 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 521 

carriers of adherent infectious material, and this method of transfer 
is accepted by Menge, Pozzi, Chiari, and Veit, but lacks definite proof. 
Hegar believes that the tubercle bacillus may enter by slight or ex- 
tensive abrasions of the mucous membrane of the vulva, vagina, or 
uterus, travel in the regular course of the lymphatic stream, and find a 
lodgment in the outer end of the Fallopian tube or the ovary. This 
belief is supported (1) by the observations of Maier, who has shown 
that puerperal inflammation of the Fallopian tubes generally begins 
at the outer end; (2) by the fact that this channel of transfer has 
anatomical support; and (3) by the frequent occurrence of tuberculous 
salpingitis after childbirth and abortion. 

The descending type of infection is more easily explained, since 
Pirmer has demonstrated that fine bodies (cinnabar or Chinese ink) 
injected into the peritoneal cavity will soon find their way into the 
tubal ostium through the tube and into the uterus. Added to this, 
we have the demonstration that the tubercle bacillus and other bacteria 
may pass through the intestinal wall in the floor of a tuberculous 
ulcer and float free in the peritoneal cavity (Hosier, Jans). The ex- 
planation here would seem to be complete. The tube may also become 
diseased through direct extension in continuity of tissue from a neigh- 
bouring tuberculous organ, usually from the peritoneum. W. Mayer 
has collected 194 cases of secondary tuberculosis of the female genital 
organs, in which number the peritoneum was diseased 110 times; in- 
deed, a number of authors have considered this to be the almost 
exclusive method of tubal infection. A secondary disease of the Fal- 
lopian tube does not invariably result from a tuberculous peritonitis, 
however, as will be shown by the fact that Schramm found an idio- 
pathic tuberculous peritonitis without disease of the tube 33 times 
in 3,356 autopsies. Tuberculous tumours of the rectum, sigmoid, or 
mesenteric glands, may also communicate the infection directly to an 
adherent tube. 

An infection by way of the blood stream (hematogenous infection) 
remains to be mentioned, and there is no reason why this method 
should not be given the importance as a causative factor in the genital 
tract that is attached to it in bone, joint, and brain tuberculosis. The 
point of entrance of the germs may show no tuberculous changes and 
the only lesion in the entire body may be that in the tube; or the 
primary focus in the lung or in a bone, from which the embolus came, 
may be so small and difficult to find that a mistaken diagnosis of a 
primary disease may be made (Williams). 

Morbid Anatomy. — The lesions of tuberculous salpingitis are usu- 
ally bilateral although present in a different degree on the two sides. 
The general appearance of the organs will vary greatly with the stage, 
character, and severity of the inflammatory process. The type desig- 
nated by Williams as " unsuspected tubal tuberculosis " will of course 
not be observed, and the more advanced cases will present every change 
from slight enlargement to the most extensive matting together of 



522 



A TEXT-BOOK OF GYNECOLOGY 



pelvic contents and the formation of abscesses. The tubes that we 
usually see have already undergone a more or less high degree of 
change and their form does not vary as a rule in any way from that 
presented by ordinary pus tubes, and they present the features of a 
well-developed tuberculosis (Fig. 219). This picture of tuberculosis 
is formed by the presence of typical grayish-yellow or transparent mili- 
ary nodules on the surface; the lumen is dilated and filled by caseous 




Fig. 219.— "The features of a well - developed tuberculosis": A, tube wall thickened; 
i?, mucous membrane of the tube in a condition of adenomatous hyperplasia; C, broad 
ligament, much thickened; D, miliary tubercles on the peritoneal surface and in the 
mucosa; E, the lumen of the tube surrounded by a zone of caseous degeneration. — 
Whitacre. 



material, and adhesions bind the tube down in the pelvis. The ab- 
dominal end may be open, when the fimbria? are swollen and pushed 
over the opening; or, the ostium may be closed by a plug formed of 
pseudomembrane and tubercle tissue, when the tube may become 
dilated to almost any degree (Fig. 220), and may assume most sur- 
prising shapes. Veit has seen a case in which the isthmus of the tube 
was so distended as to give the appearance of an extension outward of 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 523 

the uterine cornu (Fig. 221). The tube contents, according to their 
constituents, may be fluid, milky, of the consistence of cream or cheese, 























^^F 






^L 


"^5^ 














^■^^^^ 












SB 


|t?j.HQPwns 















Fig. 220 (Yeit). — " The tube may become dilated to almost any degree." — Whitacre (p. 522). 

or at times chalky. The usual type is a grayish-yellow cheesy mass. 
The mucous membrane also shows marked changes and is covered by 




Fig. 221. — " Veit has seen a ease in which the isthmus of the tube was so distended as to give 
the appearance of an extension outward of the uterine cornu." — Whitacre. 



524 A TEXT-BOOK OF GYNECOLOGY 

tubercles in every stage of metamorphosis. In prolonged cases it may 
be entirely replaced by a necrotic caseous mass. The wall of the tube is 
usually thickened. 

The form of such tumours does not differ from that of tubes other- 
wise inflamed. Tumours of sausage, retort, and torpedo shape are 
the usual forms, while Hegar has placed special weight, first, on a 
rosary -shaped swelling, and, secondly, on a swelling at the isthmus of the 
tube that gives the appearance of an extension outward of the horn of 
the uterus. A closure of the outer end may result in a dilatation of 
the tube and a collection of pus that may reach two quarts (Stemann). 
The tumour will be further modified by the development of peritoneal 
products and adhesions. The position of the tumour shows all the 
variations that we might expect in severe inflammatory change. Swi- 
talski reports a case in which a tubal tumour the thickness of a finger 
was found in front of the uterus, lying on top of, and involving, sec- 
ondarily, the bladder wall. 

According to the manner of beginning, the lesions may be divided 
into an acute and a chronic tubal tuberculosis. The former usually fol- 
lows a secondary, and the latter a primary, infection. 

The acute form is characterized by an involvement mainly of the 
ampulla, and a rapid breaking down of the tuberculous mucous mem- 
brane which becomes changed into a cheesy detritus. Through this 
process the muscle is destroyed in part or in its entirety, and the 
lumen is widened to a certain extent. Microscopically, the mucous 
membrane shows a rich round-celled infiltration and numerous miliary 
tubercles but very few giant cells, owing to the promptness with which 
a central necrosis occurs in the tubercles. As the process advances, 
the mucous membrane becomes changed into a detritus containing 
many tubercle bacilli. The muscle layer shows distinct miliary 
tubercles between the fibres or caseous areas. 

In the chronic form the abdominal end of the tube becomes promptly 
closed and a pyosalpinx forms. The destruction of the mucous mem- 
brane is much slower, the tube may be very much dilated by pus 
formation, and the thickening of the muscular wall may reach such 
a high degree that the tube is changed into a hard, stiff formation. 
Microscopically, this form begins by the deposit of minute miliary 
tubercles in the mucous membrane beneath the epithelial surface. 
These tubercles are discrete, typical in their structure, show very little 
tendency to caseate, and remain confined to the mucosa for a long time 
(Fig. 222). This stage forms the type of "unsuspected tubal tuber- 
culosis," described by Williams, and will be revealed only on micro- 
scopic examination. An increased number of tubercles, however, will 
result in an infiltration and swelling of the folds of the mucous mem- 
brane, and the dilated lumen will be filled by what seems to be a caseous 
tuberculous mass but is found microscopically not to have broken down 
in any part (Martin). At other times the tubercle bacillus excites 
decided proliferation in the glandular elements to the degree of dis- 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 595 




Fig. 2-2-2. — - These tubercles are discrete, typical in their 
structure. . . . and remain confined to the mucosa 
for a long time." — Whitacbe page 524 . 



tinct adenomatous tumour formations. This lias been observed with 
sufficient frequency to call for special mention (Wolff, Orthniann, 
Friedlander, Landau, Bheinstein, and others), and is considered to be a 
hyperplasia analogous to 
that of the epithelium 
in lupus. These growths 
may be confused with ma- 
lignant tumours and it 
is important to remember 
their tuberculous origin. 

The tubercles of the 
chronic type have many 
giant cells and few tuber- 
cle bacilli. The muscu- 
laris does not become 
involved until very late 
in the disease, and its 
marked thickening must 
be looked upon as a hy- 
pertrophy of the muscle 
and connective-tissue ele- 
ments, and not as a tuber- 
culous growth. Tubercles 
may be found in the mus- 

cularis in the late stages. The serosa may be thickly covered by hemp- 
seed-sized tubercles and the tubal ostium is usually closed by adhesions. 
A true pyosalpingitis manifests itself in relatively few cases (Schroder, 
"Winekel, Martin, Minister). 

That not all cases permit of these lines of division into an acute 
and a chronic form is certain, but in general it will serve as a working 
basis. "Williams has made a division into three forms: a miliary, a 
chronic diffuse, and a chronic fibroid form. His miliary form corre- 
sponds to the early stage of the chronic form described above: while 
the chronic fibroid form is described as one characterized by a rich 
formation of fibrous tissue in and around the miliary tubercles, and 
showing almost no tendency to caseation. 

Both the closing of the tubal ostium and the fibrous thickenings 
found in the chronic forms seem to be a curative effort on the part 
of Nature. Yet it must be remembered that the caseous contents may 
escape from the open end of a tube into the free abdominal cavity 
(Hegar). and furthermore that encapsulation does not always occur 
when this does take place (Knauer). 

Spontaneous healing may also certainly take place by a calcification 
of the focus (Kiwisch, Eokitansky), while a tuberculous abscess may 
heal by rupturing into the rectum, the vermiform appendix, or the 
small intestine (Veit). 

The gonococcus has been found a number of times in tuberculous 



526 A TEXT-BOOK OF GYNECOLOGY 

tubes, and it would seem probable that a pre-existing gonorrheal sal- 
pingitis would predispose the tube to a tuberculous infection. 

Symptoms. — The symptoms of the disease are in general those of 
ordinary salpingitis, and may range in severity from entire absence in 
the miliary form to the most severe symptoms of salpingitis and pelvic 
abscess. Indeed, the symptoms, subjective and objective, are so little 
characteristic that the abdomen of such patients is usually opened for 
adherent tubes and ovaries or for pyosalpingitis. Not infrequently a 
family history of tuberculosis or the discovery of tuberculosis in other 
parts of the body or in the husband (Menge), serves as a starting point 
for the accurate interpretation of the symptoms. In cases of primary 
tuberculosis of the tubes, an important symptom is a more profuse 
and painful menstruation (Martin), while amenorrhcea is of course 
present in the cases of coincident phthisis. The pain may occur on 
one or both sides, but it must remain a question as to how much of 
the pain depends upon the tube and how much upon the peritoneum. 
The temperature is not elevated. Ascites may be present. Symptoms 
may persist practically unchanged for a long time, as has been shown 
by Werth, who reported a case in which the tuberculous process re- 
mained confined to the tube for two years and a half. 

An extension of the process to the peritoneum gives much more 
characteristic features to the symptoms. A progressively increasing 
pelvic trouble, chronic in its nature and associated with tumour forma- 
tion, the matting together of the intestines, disturbance of the rectum, 
and encysted ascitic fluid extending above the pubes, generally indi- 
cate tuberculosis. A secondary infection by the pyogenic cocci will 
of course initiate the more acute symptoms of sepsis. Lastly, a primary 
tuberculosis of the tube may lead to tuberculous peritonitis, phthisis, 
marasmus, or septic peritonitis. 

Diagnosis. — From what has been said of the symptomatology it is 
apparent that the diagnosis is extremely difficult; indeed, Gehle, in 
1881, stated that a positive diagnosis of genital tuberculosis could not 
be made. This statement, of course, loses all authority with reference 
to the accessible parts of the genital tract since the discovery of the 
tubercle bacillus, but it still holds true in a marked degree of those 
cases of tubal and ovarian disease in which the uterine curettings do 
not contain tubercle bacilli. 

The history of the patient, heredity, and the existence of tuber- 
culosis in other organs, are important points in the diagnosis. Hegar 
believes that a rosary-formed swelling of the tube occurs more fre- 
quently in this than in any other form of tubal disease, and has placed 
special stress upon a swelling of the isthmus of the tube at its exit 
from the uterine horn (Martin). Other writers believe that a swelling 
in the outer end is the common form of tumour formation. Attention 
has also been called by many observers to the hardness of the tumour, 
but it is certainly true that these features of form and consistence may 
be present likewise in pyosalpingitis. 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 527 

If the tubes are not too firmly bound down, the diagnosis may be 
greatly facilitated by feeling tuberculous nodules on the surface of 
the tube, on the pelvic peritoneum, or on the posterior surface of the 
uterus. Edebohls lays great stress on a plaquelike thickening of the 
peritoneum. Osier says " the association of a tubal tumour with an 
ill-defined anomalous mass in the abdominal cavity should arouse sus- 
picion at once." Tubercle bacilli may be found in the secretions of 
the uterus even though that organ be uninvolved, and Edebohls has 
once aspirated an abscess of the tube and discovered tubercle bacilli 
in the pus. 

Prognosis. — The prognosis is always grave in either the primary or 
the secondary form. In the former, because of the marked tendency 
to extend to the peritoneum or lungs, and the tendency to a secondary 
pyogenic infection of a caseous mass; in the latter, because all these 
symptoms are added to the seriousness of the primary disease. The 
brilliant results obtained by the gynecologist, even in advanced cases, 
have done much during the past few years to counteract the absolutely 
bad prognosis of earlier writers, and we now know that a complete 
cure of the condition will follow excision in a great many of the 
primary cases, and that life will be much prolonged in the advanced 
cases. We are indebted to Hegar for this radical change in prognosis. 

Treatment. — The prophylactic treatment of tuberculous salpingitis 
consists in cleanliness on the part of the physician and patient and in 
abstinence from marriage and coitus by people suffering from genital 
tuberculosis. 

By reason of the great difficulties, nay, the impossibility, of making 
a diagnosis in many cases of primary tuberculosis, we are not often 
called upon to decide the question of treatment. Yet when the disease 
is discovered during an operation done for other conditions or when a 
diagnosis is made, there can be no question as to the advisability of 
radical removal. When the tubal disease is associated with tuberculous 
peritonitis, this condition gives an additional reason for operation rather 
than a contraindication. In patients suffering from phthisis, the treat- 
ment of a secondary tubal disease becomes a much more difficult prob- 
lem. In general, the condition of the patient must be carefully con- 
sidered and her chances of life weighed with and without operation. In 
other words, early cases should be operated on, late cases should not. 

A double tuberculous salpingitis does not necessarily call for hyster- 
ectomy, even though the uterus does show involvement in a majority of 
cases, since curetting, combined with the natural resisting power of 
the endometrium, may overcome a mild infection. 

A tonic treatment, pure air, and good hygienic surroundings, have 
the same value as in tuberculosis of other parts of the body. 

The operative treatment of these cases is the only rational one, 
and the excellent results reported by a number of operators will justify 
excision, even in those cases in which the disease has extended far 
beyond the appendages. 



528 A TEXT-BOOK OP GYNECOLOGY 

Bacillus Coli Infection of the Fallopian Tubes. — The Bacillus coli 
communis lias been found to be the essential micro-organism in certain 
cases of tubal infection. Deaver (Virginia Medical Semimonthly) states 
that there is frequently a close relationship between acute catarrhal 
appendicitis and right-sided acute salpingitis. While he mentions these 
as separate conditions, calling for consideration of their respective 
symptomatology for diagnostitial purposes, the causal relationship 
between the two is nevertheless suggested. The role of the Bacillus 
coli communis in appendicitis is well understood, but the extension of 
its influence to the Fallopian tube is not so easily comprehended or so 
generally recognised. Cases of salpingitis, however, in which the bacil- 
lus coli was present, have been reported by Morax, Girode, Hartmann, 
Doyen, and Reymond. Individual cases have also been reported by 
Guyon, Tuffier, and Schauta. 

The causation of this infection may be summarized under the head 
of intestinal adhesion. The intestinal origin of this infection is em- 
phasized by Reymond, who failed to find it in a single case in which the 
tube was not adherent to the intestine. Actual perforation of the 
intestine, however, does not seem to be essential to enable the bacillus 
coli to migrate from its native habitat to the lumen of the Fallopian 
tubes; on the contrary, there is ample evidence that the infection takes 
place by direct passage through the adhesions. There is no evidence, 
however, to justify the denial of a possible invasion of the tubes by 
progressive infection of the mucous tract through the vagina and 
uterus. The fact that the bacillus coli has been found in the vagina 
indicates the possibility of a general infection of the genital tract by 
that route. In six cases studied by Reymond and Magill, the condi- 
tions were all favourable for direct infection from the intestines. In 
one case in particular the right tube was adherent to the intestine 
and contained the bacillus coli, while the left tube, which was not 
attached to the intestine, did not contain that micro-organism. It 
would seem that the bacillus coli never occurs singly as an infectious 
element in the Fallopian tubes; on the contrary, other fine bacteria 
appear to accompany the colon bacillus, but they have not been classi- 
fied. These bacteria have been observed by Witte, Morax, and Rey- 
mond and Magill, as small rods much more slender than the colon 
bacillus, immovable, colourable by Gram's method, and of variable 
length. They seem to add to the off ensiveness of the pus in which they 
are found. 

The symptoms of bacillus coli infection of the Fallopian tubes are 
essentially those of a pyosalpinx. In view of the fact that this bacillus 
has not been demonstrated in the tube in the absence of tubo-intestinal 
adhesions, and of the further fact that such adhesions only occur as the 
result of a previous infection of the tube, it follows that the history 
of the case must embrace the symptoms of the preliminary infection. 
This may be gonococcous infection or a streptococcous infection, or 
it may be a so-called mixed infection, by which is implied that un- 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 529 

differentiated infection which is probably responsible for the majority 
of pus tubes. AYhen, however, the bacillus coli penetrates the Fallopian 
tubes, the symptoms are more or less violent, the temperature running 
very high, sometimes to 105° F., following an initial chill. The rigors 
may be repeated, followed each time by exacerbation of the tempera- 
ture, with increasing evidences of systemic intoxication, verging to the 
fatal point. Spontaneous relief may occur, however, by the abscess 
breaking into the intestine and thus draining away. 

The pathology of this form of infection does not differ in essential 
particulars from that already given. (See Morbid Histology of Sal- 
pingitis.) The bacilli are found in variable quantity in the pus; some- 
times in such quantity as to suggest a drop of culture bouillon. This, 
however, is exceptional, as in other cases the bacteria are so rare 
that microscopic examination of the pus is negative, the existence of 
the micro-organisms being revealed only by cultures. Leucocytes are 
rare in the pus, while the epithelial cells are more numerous. The 
manner in which the bacillus coli attacks the epithelium does not seem 
to be settled. If it is granted that the organism finds its way into the 
tube through the septum formed by tubo-intestinal adhesion, it follows, 
as a logical result, that it must approach the epithelium from beneath; 
whereas, if the method of invasion is through the uterus, it, like the 
gonococcus, attacks the epithelium from its free surface. Eeymond 
and Magill record the significant fact that in all sections made and 
coloured by them with Xicolle's method, they were never able to find 
the bacteria elsewhere than in the salpingo-ovarian pocket, in the 
midst of eliminated cells, and at the surface of the wall. The progres- 
sive accumulation of pus is more rapid than in the ordinary infections, 
and results in extreme distention of the tube which may rupture either 
into the peritoneal cavity, or, as more frequently happens, into the 
intestine. 

Pneumococcous Infection of the Fallopian Tubes. — The infection of 
the Fallopian tubes by the pneumococcus is rare, Eeymond and Magill 
never having observed a case, although one each has been reported 
by AVertheim, Zweifel, and Frommel. It would seem that in this form 
of infection the mischief is always limited to the tube and does not ex- 
tend to the ovaries. The majority of the cases are unilateral, the pus 
being small in quantity and the tube being closed at its pavilion. The 
investigators have not recorded any peculiar appearances in the micro- 
scopical sections from these cases. 

The symptoms in the cases on record are those of an acute onset 
followed by high temperature. It would seem either that the pneumo- 
coccus is of varying virulence, or that the patients possess different 
degrees of susceptibility, since the escape of pus into the peritoneum 
in Zweifel's case caused no accident, while it proved rapidly fatal in 
the cases reported by Frommel and "Witte. 

The causation of this form of infection seems to be shrouded in 
mystery, for no satisfactory explanation has been made of the manner 
35 



530 A TEXT-BOOK OF GYNECOLOGY 

or means by which this micro-organism is conveyed from its natural 
habitat to the Fallopian tubes. In none of the cases has pneumonia 
been present, although Stroganoff has observed a pelvic abscess that 
contained capped diplococci in several cases following pneumonia. It 
is stated that in cases of salpingitis no history of general disease which 
might be considered the primitive cause has been recorded. An exami- 
nation of all the testimony tends to render untenable an hypothesis of 
the systemic origin of the infection. The probability of its entrance 
through the genital tract seems to be better founded. The cases of 
Witte and Frommel show that the infection was consecutive to puer- 
peral accidents; while gonorrhoea was the antecedent factor in the 
cases of Girode and Zweifel. The facts, however, that the pneumo- 
coccus exists normally in the saliva, and that among certain people of 
depraved habits the saliva is sometimes used as a lubricant in vaginal 
manipulations, may explain its presence in that canal, where Doyen 
and others assert that they have found it. In view of the fact, how- 
ever, that its normal medium is alkaline, it is hardly to be assumed that 
it will find a congenial environment in the presence of the acid 
products of the bacillus of Doderlein. The assumption, therefore, that 
the pneumococcus is to be classified among the normal bacteria of the 
vagina seems to be gratuitous. 

Staphylococcous Infection of the Fallopian Tubes. — This condition 
has been assumed to be of frequent occurrence. This assumption, 
which does not seem to be well-founded, is manifestly based upon the 
important role which the staphylococci play in infections in general. 
These micro-organisms are not demonstrably present in a large propor- 
tion of salpingitides. Schauta found them but 4 times in 144 examina- 
tions. Menge found them once in 26 cases, Morax once in 33, while 
Witte found them but twice. Boisleux reports that he has observed 
them several times. It is a notable fact that several observers who have 
found them have discovered other pathogenic micro-organisms present 
in the same cases. Eeymond and Magill have failed to find them, and, 
while not denying the accuracy of other observations, suggest that con- 
fusion may have arisen from the fact that there are found in and near 
the Fallopian tubes, saprophytes which may easily be confounded with 
the white and golden staphylococcus. The microscopic illusion is 
heightened by the fact that these saprophytes offer the same appearance 
on the slide and show cultural properties similar to the staphylococci. 

Saprophytic Infection of the Fallopian Tubes. — Witte has observed 
harmless bacteria, in company with those possessing pathogenic prop- 
erties, in the Fallopian tubes, but, like Eeymond, has not come to a 
conclusion as to their proper classification. The latter notes the 
significant fact that they resemble the species which normally inhabit 
the lower portion of the genital tract, but is not prepared to believe 
that they are indigenous to the tubes. The conclusion of Sinclair, that 
the Fallopian tubes are normally free from bacteria, is in accordance 
with this view. (See Bacteria of the Fallopian Tubes in Health.) The 



INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 531 

explanation of their presence in the tubes rests upon purely theoretic 
grounds. The fact that they are always found in connection with 
pathogenic bacteria suggests that they migrate thither under the escort 
of their more virulent congeners. They do not penetrate deeply into 
the mucosa but live upon its surface. In those cases in which they 
seem to be more deeply embedded, it is found, upon careful exami- 
nation, that they are actually within an epithelial cul-de-sac which has 
become more or less displaced by the inflammatory thickening of 
the membrane. They are not discoverable in the muscular tunic. 

Septic Vibrion Infection of the Fallopian Tubes. — Infection by the 
vibrion septique of Pasteur (Bacillus cedematis maligni) has been found 
in the Fallopian tubes by AVitte. This organism, which has rounded 
edges, and varies from 0.8 /x to 1 yw. in thickness and from 2 /x to 10 /x in 
length, was obtained in pure cultures by Liborius. It produces in the 
lower animals a hemorrhagic oedema in the subcutaneous tissues into 
which it is injected. The infection in such cases is limited to the 
immediate area of injection until after death, when it becomes rapidly 
diffused throughout the system. It is believed to be the cause of 
emphysematous gangrene in the human subject — although the role 
that it was presumed to play in producing gaseous phlegmons, is now 
known to be shared by the Bacillus aerogenes capsulatus. The gaseous 
manifestations were present in AVitte's case of pyosalpinx. It has also 
been found by Giglio in company with the Staphylococcus pyogenes 
aureus in perimetric abscess. Its method of invasion of the Fallopian 
tubes, and the exact part that it plays in general pathology, are not 
accurately understood. 

Actinomycosis of the Fallopian Tubes. — This condition has been 
observed by Zemann, the lumen of the tube being filled with pus in 
which the parasite abounded. The micro-organism (Streptothrix actino- 
myces) attacked the walls of the tubes, which were thickened and 
granular. The origin of the infection was not determined. 



CHAPTEE XXXV 

TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 

The natural course and termination of inflammatory diseases of the Fallopian 
tubes — Hygienic treatment — Medicinal treatment — Local treatment — Massage 
— Electricity — Drainage : Indications ; varieties — Vaginal incision or puncture 
— Inguinal or inguino-vaginal incision — Abdominal and abdominovaginal 
incision — Rectal puncture — Aspiration — Conservative operations on the tubes 
— Radical treatment — Salpingectomy — Tait's operation; modifications of Tait's 
operation — Abdominal panhysterectomy — Doyen's operation (vaginal hysterec- 
tomy); modifications, indications, and limitations. 

The Natural Course and Termination of Inflammatory Diseases of 
the Tubes. — The treatment of any given disease should be based upon 
the knowledge of the natural history of that disease. The application 
of this rule to the treatment of infections of the Fallopian tubes, in- 
volves primarily a consideration of the natural termination, uninflu- 
enced by operative treatment, of the inflammatory diseases induced by 
the infection. This, as stated by Clark, can not be done accurately in 
our present state of knowledge, for the reason that, during the last 
decade, in which the most advanced studies in gynecology have been 
made, there has been much greater activity, in the operative field than 
in that of simple palliative treatment, or the treatment by topical appli- 
cations and douches; consequently, no series of cases sufficiently large 
to offer reliable statistics has been reported. Notwithstanding this 
deficiency in statistics, general observations, as recorded by many gyne- 
cologists, point very strongly to the possibility of a restoration ad inte- 
grum in many cases of salpingitis which have hitherto been subjected 
to radical operations. In considering the prognosis in the acute in- 
flammations of the tube, two principles in the pathology of these organs 
must be borne in mind. First, many tubal infections are self -limited; 
and, secondly, the mucous membrane of the tube is extremely difficult 
of destruction. With a decrease therefore in the virulence or cessation 
of the infection in the simple acute inflammations, the second factor 
becomes active and tends to restore the tube to the normal condition. 
Whether a perfect restoration occurs, depends upon the extent of the 
injury. While we accept unhesitatingly the statement that the ma- 
jority of cases of simple tubal catarrh, and even of purulent salpingitis, 
terminate in a return to the normal, just as do acute catarrhal and sup- 
532 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 533 

purative processes in other mucous membranes, nevertheless when a 
widespread, round-celled infiltration of the muscular layers of the 
tube occurs, with a subsequent formation of new connective tissue, 
which renders the tissues dense, nonvascular, and more or less of a 
low vitalized type, an anatomic restoration is manifestly impossible. 
From the purely functional standpoint, however, this question is to be 
considered in another light. Accepting as true the statement that 
sterility in the latter class of cases is the rule, we should not by any 
means unqualifiedly infer that these patients will become chronic in- 
valids, for according to our observation, some women even with exten- 
sive adhesions and distortion of the tubes still suffer little or no pelvic 
pain. 

With the conservative spirit which now prevails among gynecolo- 
gists in regard to the treatment of this special class of diseases, we 
shall no doubt find with the accumulation of accurate records that in 
simple catarrhal inflammations, and even in cases of undoubted hydro- 
salpinx, a self-limitation of the disease occurs, especially under the 
influence of rest, freedom from sexual intercourse, and the proper ap- 
plication of douches and other remedies. 

The ordinary pyogenic cocci, such as the streptococcus, staphylo- 
coccus, colon bacillus, etc., appear to be more virulent in their imme- 
diate action than the gonococcus, but the latter is much more persistent 
and is especially prone to recur. When the ordinary pyogenic cocci 
gain access to the tube, their cycle of activity ends with the acute 
attack, after which, absorption in the case of hydrosalpinx, or even of 
pyosalpinx, may occur, whereas the gonococcus is frequently very per- 
sistent and is self -perpetuating. Once infected with it, the pathological 
process may extend over months and years, now better, now worse, de- 
pending upon the renewed activity of the gonococcus. These patients, 
therefore, are prone to become chronic invalids. 

There is little danger to life in the acute or recurrent gonorrheal 
attacks so far as the immediate effect is concerned, but the patient may 
drag out a miserable existence, suffering more or less pelvic pain for 
years. So far as the ultimate prognosis is concerned, our present 
knowledge seems to indicate a more permanent recovery in those cases 
which survive the primary infection from the ordinary pyogenic organ- 
ism than from the gonococcus, at least so far as a restoration of the 
patient to a condition of freedom from pain and discomfort is con- 
cerned. Hydrosalpinx, while often very painful, is not dangerous, and 
patients tend to recover without operation, the fluid being absorbed 
just as in similar collections in other cavities. When aided by inci- 
sion and puncture, the return to the normal is greatly facilitated. 

While the pus of a pyosalpinx may, as stated, ultimately be ab- 
sorbed, this appears to be the exception rather than the rule, for as in 
other collections of pus, Nature attempts to establish an exit; at 
least this is true in cases in which the pyosalpinx reaches a consid- 
erable size. 



534 A TEXT-BOOK OF GYNECOLOGY 

When the tube is small, slow gradual inspissation of the pus may 
occur, leaving, in its later stages, only a granular, cheesy matter. 

In some of these cases, small calcareous bodies, which appear to be 
the residual debris of the inspissated pus, are also found. With the 
progressive accumulation of pus in the tubes, the coincident perisal- 
pingitis results in firm adhesions to the surrounding organs, that 
prevent the rupture of the tube into the abdominal cavity. Pelvic 
peritonitis from contiguity of organs is quite common, in fact is almost 
an invariable rule, but widespread general peritonitis is quite excep- 
tional as a result of purulent contamination through the rupture of the 
tube. For this reason, a procrastinating policy, so far as operation is 
concerned, should usually be pursued in gonorrheal salpingitis, even if 
pyosalpinx is formed; for it is better to wait for the organisms to expend 
their virulence and die, rather than to operate in the acute stage when 
the temperature is considerably above normal. The tube, when dis- 
tended with pus, frequently drops down into the pelvis posteriorly to 
the uterus, and often in cases of double pyosalpinx the retort-shaped 
vestibular ends come into contact. Following the rule with all puru- 
lent collections, the pus tends to rupture in the direction of least 
resistance. The isthmiac end of the tube being either occluded or 
very resistant, offers an effectual bar to the escape of the purulent mat- 
ter into the uterus. The situation of the bladder, anterior to the uterus, 
while the pyosalpinx is posterior, renders this viscus a comparatively 
infrequent channel of egress. The intestinal canal, therefore, forms 
the most likely cavity into which the abscess will tend to evacuate 
itself. Because of the dependent position of the tubes in Douglas's 
cul-de-sac and of the intimate adhesion of the upper third of the 
rectum and the lower portion of the sigmoid flexure to them, rupture 
usually occurs at these points, although the small intestine may prove 
Nature's point of election. When once evacuated, the further secretion 
of pus may cease and obliteration of the cavity by granulation may oc- 
cur; or, on the other hand, reinfection by the colon bacillus or other in- 
testinal organism may take place through the intestinal opening, and a 
well-nigh interminable purulent process be inaugurated. Certainly, 
after a rupture into the intestinal canal has occurred, a reasonable time 
should be given for the closure of the fistulous tract before an operation 
is resorted to; for these are very unfavourable cases, the intestinal 
lesion introducing a dangerous factor into the operative treatment. In 
some cases, the pus points in the inguinal region, or gravitates down- 
ward under Poupart's ligament, appearing as a fluctuating swelling 
in the femoral canal. 

Clark concludes a careful study of the natural history of inflam- 
matory diseases of the Fallopian tubes with the statement that, while 
palliative treatment should, by all means, be employed in the simpler non- 
purulent inflammations of the tube, so far we can see no reason to 
modify the surgical rule to liberate the pus by means of an operation rather 
than to wait for its natural evacuation ; for Nature's method is usually 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 535 

very inferior to the clean, careful work of a good surgeon. If left alone, 
the patient is subjected to many months of very serious invalidism, 
whereas proper operative treatment is followed by much more certain 
and radical relief. 

Hygienic Treatment. — While the prognosis in acute salpingitis 
varies according to the etiology, whether simple, gonorrhoeal, or septic, 
the aim of the medical treatment in each variety is practically the 
same. We can not expect to arrest the process after it has once ex- 
tended to the tube, but we can assist Nature's method of cure, which 
consists in the absorption of inflammatory products, the occlusion of 
the distal end, or the adhesion of the diseased tube to adjacent organs 
so that infectious fluids are shut off' from the general cavity. Abso- 
lute rest in the recumbent position must be insisted upon, the patient 
not being allowed to leave her bed for any purpose. Sexual excitement 
is especially to be avoided — the husband being strictly cautioned as 
to this point. If the menstrual flow appears during the acute attack, 
these precautions are still more necessary. The regulation of the 
bowels is of primary importance, as thorough purgation often cuts 
short an attack, or at least limits the inflammatory process. Half- 
grain tablets of calomel, one every half hour, followed by teaspoonful 
doses of sulphate of magnesium or phosphate of sodium, are usually 
followed by several loose movements. If the stomach is irritable, six 
or eight ounces of a saturated solution of salts, may be introduced into 
the bowel through a long rectal tube. After the bowels have been 
opened, the saline laxative should be repeated daily. If the tempera- 
ture is elevated above 101° F., an ice bag or cold-water coil, applied 
over the lower abdomen, not only relieves pain, but often controls the 
accompanying peritonitis. Some patients can not tolerate cold, but 
find more relief from hot stupes or poultices. Hot vaginal douches 
(110° to 115° F.) are exceedingly useful in the acute stage, but they 
should be given every six hours, not less than a gallon of water being 
used each time. High enemata of saline solution not only relieve tym- 
panites, but stimulate the renal functions. Pain is best relieved by 
codeine suppositories, hypodermatic injections of morphine being given 
only when absolutely necessary. Strychnine is a more reliable stimu- 
lant than alcohol. 

In short, the treatment of a case of acute salpingitis is identical with 
that of localized peritonitis, with the details of which the reader is suf- 
ficiently familiar. If adopted promptly and carried out thoroughly, most 
nonseptic cases will either go on to resolution with more or less restora- 
tion of function, or the patient will recover with thickened and adherent 
tubes, to become the subject of future medical or surgical attention. 
In the nonsurgical treatment of chronic salpingitis the physician seeks 
to relieve pain and disability, to promote the absorption of exudates and 
the stretching of adhesions around an imprisoned tube, and to restore 
its physiologic functions so that conception may become a possibility. 
While considerable confidence may be felt in reparative natural pro- 



536 A TEXT-BOOK OF GYNECOLOGY 

cesses, since the physician can not know the exact anatomic condition 
without opening the abdomen, he should be careful about promising 
a complete cure or entire freedom from subsequent attacks under con- 
ditions favouring fresh traumatisms or infection. It is assumed that 
the cases under consideration are those in which the tube is merely 
thickened and adherent, especially in Douglas's pouch, with or with- 
out accompanying disease of the ovary. A patient with this condition 
must be taught to take the best care of herself. She should, while tak- 
ing daily exercise in the open air, be constantly on her guard against 
over-exertion, indulgence in violent sports (golf, bicycling, or bowling), 
exposure to cold, in fact, anything which might light up a fresh attack 
of inflammation. If sexual intercourse can not be interdicted, it should 
occur at infrequent intervals, with due cautions against violence or 
excess. Unless the cheerful co-operation of the husband can be se- 
cured, all treatment will be unsatisfactory. Rest during menstruation 
is a desideratum, at least during the first two or three days. Patients 
must be taught that this is the period when they are most liable 
to recurrent attacks. The deleterious influence of pregnancy and 
abortion upon old tubal troubles is well known, so that it is quite 
within the province of the physician to caution against the risks 
attending conception in subacute cases, especially those of gonor- 
rhoeal origin. 

Medicinal Treatment. — Various drugs have been mentioned as hav- 
ing almost specific action upon tubal disease, such as bichloride of 
mercury, chlorate of potassium, and the iodides; but this action, when 
apparently beneficial, must be due rather to the improvement effected 
in the general health, especially in syphilitic subjects. Tonics and laxa- 
tives are always indicated. Careful regulation of the bowels by cas- 
cara, podophyllin, or salines, with occasional high enemata, should be 
a routine measure. Warburg's tincture, iron, and strychnine, are never 
amiss. For the correction of gastric disturbances and excess of uric 
acid, teaspoonful doses of phosphate of sodium in hot water act most 
satisfactorily; indeed, when this simple remedy is used habitually it is 
usually unnecessary to give any other laxative. The action of the kid- 
neys should be stimulated by the daily ingestion of large quantities of 
pure water. Alcoholic stimulants are to be avoided, unless strongly 
indicated on account of the weak condition of the patient, especially 
during menstruation when they are apt to be used in excess to relieve 
pain. The temptation to resort to morphine to relieve dysmenorrhcea 
is strong, but should be resisted as far as possible. If opium must be 
used, codeine, in the form of suppositories, is preferable, or the coal- 
tar derivatives may be employed without overlooking their depressing 
effect on certain subjects. Counter-irritation over the abdomen with 
blisters, leeches, or the thermo-cautery, often affords temporary relief 
to local pain, but no actual effect upon the pathologic condition within 
the pelvis is to be expected. The same comment applies to painting 
the vaginal fornix with tincture of iodine. In scanty menstruation, iron 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 537 

and manganese are indicated. Menorrhagia is treated with small doses 
of strychnine, ergot, and hydrastin, or stypticin in 2-grain doses 
every four to six hours until the profuse flow is checked. Since in these 
cases the endometrium is in a state of hyperplasia, curettement is 
usually the most direct method of relieving the symptom. It is hardly 
necessary to add that the hot vaginal douche is indispensable in the 
treatment of chronic, as well as of acute, salpingitis. 

Local Treatment. — In the medicated tampon we have probably the 
best local agent for the treatment of diseased and adherent tubes. In 
many cases it certainly relieves pain and assists in the absorption of 
exudates, as proved by the marked diminution in the size and sensi- 




Fig. 223. — " Aside from the advantage gained by supporting enlarged and displaced tul 
the habitual use of the tampon seems to improve the pelvic circulation."— Coe. 



tiveness of the pelvic tumour. That a restitutio ad integrum can be 
thus obtained, only an ultra-enthusiast would assert. Yet the per- 
sistent use of the tamponade has relieved many women from a state 
of invalidism when an operation seemed inevitable, so that they be- 
came practically well and were able to conceive and bear children. 

Glycerine, boro-glyceride, and ichthyol, are the medicaments 
usually employed — the two latter in a 10-per-cent solution in glycerine. 
Aside from the advantage gained by supporting enlarged and displaced 
tubes (Fig. 223) (especially when the uterus is retroflexed), the habitual 
use of the tampon seems to improve the pelvic circulation, while the 
ichthyol-giycerine seems to have almost a specific action upon firm exu- 
dates, which soften and melt away under its influence. In order to ac- 
complish decided results the tampon should be inserted at least two or 
three times weekly. The patient being in the knee-chest position and 



538 A TEXT-BOOK OF GYNECOLOGY 

the vaginal fornix exposed with a Sims's speculum, two pledgets of ab- 
sorbent cotton saturated with the ichthyol solution, are pushed up 
firmly against the tumour and a dry tampon is applied on them. As 
the patient becomes more tolerant greater pressure can be exerted, the 
number of tampons being increased with the view of stretching adhe- 
sions and lifting the mass out of the pelvis. The patient is instructed to 
leave them in situ for thirty-six or forty-eight hours, meanwhile wear- 
ing a napkin on account of the discharge which always occurs. After 
they are removed, hot douches are used until the next treatment. 

While patients learn to introduce the tampons themselves, it is a 
question if they ever push them beyond the cervix. To meet this objec- 
tion King has devised a tube for injecting the solution into the pos- 
terior fornix, a dry pledget being afterward inserted to retain it in 
the vagina. In practice it has been found that, in order to accom- 
plish the desired result, the tampon must be carefully introduced by 
the physician in the way described. It is impossible to do this prop- 
erly through a bivalve speculum. 

Massage. — So much has been written about pelvic massage that it 
is impossible to do more than touch upon it here. While Coe does not 
disparage this method of treatment, which has given such excellent re- 
sults, he is not enthusiastic with regard to its application to the separa- 
tion of intrapelvic adhesions. The unexpected extent and firmness of 
those often found on opening the abdomen, and the difficulty of sepa- 
rating them, even under the direct guidance of the eye, leads one 
to infer that the relief experienced from the massage of adherent tubes 
and ovaries, is due rather to improvement of the pelvic circulation and 
the general conditions of the patient, than to the actual absorption of 
exudates and the breaking up of bands of organized lymph. While an 
expert might venture in carefully selected cases to attempt the evacua- 
tion of pus and other fluids by " stripping ", a distended tube into the 
uterus, the practitioner will do well to confine his manipulations to 
cases of thickened and adherent tubes in which there is no evidence 
of subacute inflammation, and where the first careful attempt is not 
followed by unpleasant reaction. The technique is briefly as follows: 
The patient lies upon a low couch, with her clothing thoroughly loos- 
ened, the knees flexed, and the hips raised on a cushion. The operator, 
sitting on a low chair at one side, introduces one or two fingers into 
the vagina and exerts steady gentle pressure against the mass, while 
his other hand makes counter-pressure over the abdomen. Some re- 
sistance may be experienced at first, but with patience the tension of 
the muscles will be overcome, so that the opposing fingers may be 
approximated, grasping the mass between them. Light kneading with 
the abdominal hand enables him to put the adhesions on the stretch. 
The rule in pelvic massage is, not to begin with the exudate, but to 
direct the strokes upward and outward, with the view of emptying the 
pelvic veins. The first seance should be tentative, not being prolonged 
beyond five or ten minutes. If marked pain is experienced during the 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 539 

treatment, or pain and inflammatory reaction afterward, it is more than 
doubtful if it will prove beneficial. Should the first treatment be 
satisfactory, it may be repeated two or three times weekly for ten 
or fifteen minutes at a time. It is wise to suspend treatment just 
before and after the menstrual period. In order to save what has been 
gained in the way of stretching adhesions, it is well to introduce as 
firm a tampon as the patient can bear. In a favourable case, per- 
sistent massage will restore a considerable range of mobility to the 
adherent uterus and adnexa, so that it may even be possible for the 
patient to wear a soft rubber pessary with comfort. Circumscribed 
exudates are softened and absorbed and become insensitive, menstrua- 
tion becomes regular and less painful, and the patient's general health 
is sensibly improved. It need not be added that pelvic massage, as 
thus outlined, is not to be confounded with the forcible separation 
of adhesions under anaesthesia, an operation which calls for special 
tactile dexterity and is not free from risk. 

Electricity. — The extravagant claims of former electro-therapeu- 
tists are no longer regarded seriously. It is admitted that one need 
not look for any mysterious action of electricity upon diseased organs, 
whereby an anatomical cure may be obtained. It is simply an adjuvant 
in the treatment of pelvic diseases, serving to relieve pain and to 
stimulate the pelvic circulation. While, for the scientific application 
of this agent, elaborate and expensive apparatus is necessary, for ordi- 
nary office practice a good galvanic battery (preferably the dry-cell 
variety) is sufficient for gynecological treatment. A milliamperemeter, 
while useful, is not indispensable, since the patient's sensations and 
the after-effect of the treatment are the best guides in its application. 
Local pain is the indication for electricity. As in the case of mas- 
sage, the contraindications are subacute inflammation and the pres- 
ence of a suspected pus focus in or around the tube. A ball electrode, 
covered with wet clay, chamois, or absorbent cotton, and connected 
with the negative terminal, is introduced into the vagina and pressed 
against the sensitive mass, while the positive electrode (clay or wire 
gauze covered with cloth) is placed over the lower part of the abdomen. 
Beginning with a weak current, this is gradually increased up to 
30 milliamperes, or until the patient feels a distinct warmth or burn- 
ing sensation, but no pain. Women differ greatly as to the degree 
of tolerance, but it is not well to exceed 50 milliamperes. The seance 
lasts from five to fifteen minutes and may be repeated two or three times 
a week. The patient should experience subsequently a general feeling 
of well-being, with relief of the local pain. If it is found after two 
or three applications that the pain is increased, or if there is any other 
unpleasant reaction (rise of temperature, etc.). it is wiser not to persist 
with it. Intrauterine galvanization with the positive pole may be 
practised when menorrhagia is a marked symptom, but this is not 
generally recommended in connection with pelvic exudates. An 
equally good sedative effect is obtained by using the fine wire faradic 



540 A TEXT-BOOK OF GYNECOLOGY 

current with a bipolar vaginal electrode, and there is seldom any re- 
action. The patient's sensations form the best indications as to the 
strength of the current. 

In touching briefly upon the nonsurgical treatment of salpingitis, 
Coe would emphasize (1) the fact of its limitations; (2) the necessity 
for accurate diagnosis and care in the selection of cases; and (3) that 
an anatomical cure is not to he expected. It is the aim of the physician, 
with the intelligent co-operation of the patient, to relieve symptoms 
and to preserve organs which, though diseased, are not a menace to 
life, and may under judicious treatment be restored to functional use- 
fulness, if not to a normal condition. Operative intervention may 
in the end be necessary, but the patient's wish to make a fair trial of 
less radical methods should be regarded, and the results, even in cases 
which at first appear to be purely surgical, are often so good that an 
operation is avoided. If it is eventually performed, the patient's local 
and general condition have been so much improved by the preparatory 
treatment that the operation is rendered much easier and safer, and 
more satisfactory in its ultimate results. 

Treatment by Drainage. — In certain cases of purulent accumula- 
tions, not only within the Fallopian tubes, but in the lymphatics and 
in the ovaries, the condition of the patient is such that a judicious 
operator may deem it advisable to improve her condition before 
attempting the radical operation. The initial step in such a course 
of treatment must be the removal of the pus. 

The indications and limitations of drainage as a means of treatment 
in pelvic disease should be distinctly recognised. It may be said to be 
indicated in all cases in which there is manifestly an extensive accumu- 
lation of pus, and in which the active constitutional symptoms indi- 
cate that the causative pathogenic micro-organisms are not only yet 
alive, but virulent. In such cases, to attempt the removal of the Fal- 
lopian tube, for example, by abdominal section, would simply mean to 
expose the patient to an unnecessary hazard through the liability of 
rupturing the tube and consequently of contaminating the peritoneum. 
In all such cases it is better to evacuate the pus by some sort of punc- 
ture than, under the circumstances, to attempt the ablation of the 
appendages by either vaginal or abdominal incision. While this is 
true, it is nevertheless important to recognise that the treatment is 
essentially tentative; in other words, that it is a means of affording the 
patient only temporary relief, and of placing her in a reasonably safe 
condition for the more radical operation which, in the majority of 
cases, should follow. This is the only representation that the operator 
is justified in making to his patient. In numerous cases, however, 
symptomatic cures have followed drainage, but this result is never to 
be counted upon. It may be stated, as a rule, therefore, that pelvic 
drainage as an elective operation should only be employed as a tem- 
porary expedient, by which the patient may be put into a proper 
general condition for a radical operation. 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 541 



The varieties of drainage, or, in other words, the various avenues and 
instrumentalities by which drainage may be effected in these cases, 
may be summarized as follows: (a) vaginal puncture; (&) inguinal and 
inguino-vaginal incision; (c) abdominal or abdominovaginal incision; 
(d) rectal puncture; (e) aspiration. Drainage when once established 
may be maintained by a tube, by 
gauze, or by open incision. 

The vaginal incision, in certain 
cases more properly called vaginal 
puncture, is the method of election 
in the majority of cases. 

The cases which are best adapted 
to this method of drainage are those 
in which the purulent accumulation 
lies behind the uterus in the cul-de- 
sac, or behind the posterior folds of 
the broad ligament upon either side, 
or in which the suppuration has oc- 
curred primarily in the lymphatics 
of the pelvis and has burrowed 
thence posteriorly or laterally round 
the uterus and the upper portion of 
the vagina. In such cases, the prod- 
ucts of suppuration can be most 
easily removed through the vagina. 
The operation is done in various 
ways. The patient should in all in- 
stances be carefully prepared. Some 
operators prefer to place the patient 
in a recumbent posture, with her 
knees flexed well upon her thorax, 
the extreme Simon position, and, in- 
serting a perineal retractor, to locate 
the most dependent portion of the 
purulent sac or cavity, which is then 
opened with a bistoury. This is far 
from being a safe method of pro- 
cedure, for the reason that in prac- 
tically all these cases there is more 
or less distortion of the tissues and 
consequent displacement of the 

blood vessels. A free incision, therefore, in a locality which, under 
normal conditions, will be entirely safe, may result, in these cases, 
in the division of the blood vessels and a consequent serious and often 
fatal hemorrhage. It is better, therefore, to adopt the method de- 
scribed many years ago by Clinton Gushing and to make this opening 
by means of a dilating plunger. 




Fig. 



224. — " Eeed uses a sharp-pointed 
curved dilator " (page 542). 



542 A TEXT-BOOK OF GYNECOLOGY 

This consists in a pair of sharp-pointed dilators which are easily 
inserted, and, when opened, simply tear an orifice large enongh to per- 
mit free drainage. Eeed uses a sharp-pointed curved dilator (Fig. 224) 
and prefers to have the patient in a recumbent posture with her knees 
but moderately flexed, to have no perineal retractor, but to use 
his finger, exclusively, as a guide for directing the instrument, which 
can thus be inserted with greater accuracy in any direction (Fig. 225). 




Fig. 225.—" Reed prefers to use his linger, exclusively, as a guide for directing the instrument." 



The index finger should be inserted into the orifice thus formed, 
no hesitancy being experienced in exercising the necessary force to 
accomplish this end. A free exploration of the cavity is thus made, 
the abscess sac is washed out, first with a clear sterilized saline solu- 
tion, and afterward with pure peroxide. Reed has latterly thrown in 
freely a solution of 95-per-cent carbolic acid, rinsing the part imme- 
diately with pure alcohol, and has found it the most effective anti- 
septic procedure that he has ever employed. After this, the cavity may 
be packed with sterilized bichloride gauze, or the drainage may be 
kept up, either from the start, or after the removal of the gauze by 
a self-retaining tube. This is easily prepared, as shown in Fig. 46, 
page 115, a T being formed. The arms of this T are together clasped 
in the tip of long forceps by means of which the tube is carried through 
the orifice at the vault of the vagina and the flaps allowed to expand 
in the pus cavity. A tube thus made and inserted may be worn for 
a week or even months without removal (Fig. 226). 

The inguinal or inguino-vaginal incision is practised in certain 
cases where the pus has accumulated in the retroperitoneal structures, 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 543 

and has lifted up and practically obliterated the folds of the broad 
ligament. Such accumulations occasionally occur in positions so re- 
mote from the vagina, and so distinctly above or surrounding the 
important blood vessels to the side of the uterus, that it is necessary 
to avoid the vaginal avenue of approach. It sometimes happens that 
a diagnosis of the exact condition and location of this accumulation 
can not be made until after the peritoneal cavity has been opened. 
The median incision, therefore, merely subserves an exploratory pur- 




Fig. 226. — " A tube thus made and inserted may be worn for weeks or even months without 
removal." — Eeed (page 542). 

pose. With the finger on the inside of the peritoneal cavity and acting 
as a guide, an incision is made along the line of Poupart's ligament, 
just above its upper border, 3 to 5 centimetres in length. This incision 
is carried down through the fascia, below the peritoneal duplication, 
which is lifted by either the finger or a blunt dissector or the handle 
of a bistoury, the instrument thus employed being pushed forward 
until the pus cavity is reached. The operation may stop at this 
point, the pus cavity being treated by careful irrigation with a saline 
solution followed by peroxide, and then by 95-per-cent carbolic acid, 
followed, in turn, by the alcohol. It should then be packed with gauze 
or treated with drainage by tube. If the pus pocket has been found 



544 



A TEXT-BOOK OF GYNECOLOGY 



Fig. 227. — " ... by making two openings, one a little above 
the other." — Reed. 



to be sacculated and to contain a considerable amount of granulation 
tissue, it is probable that suppuration will be more or less indefinitely 
continued; to dispose of it, it would be better to secure through-and- 
through drainage and thus to take advantage of the force of gravity in 
disposing of the discharge. This is readily done by introducing within 
the pus cavity the index finger of the right hand, carrying Eeed's 

dilator through to the 
^ vaginal vault or to the 
fornix, as the case may 
be, and with the in- 
dex finger of the other 
hand acting as a guide in the vagina, pushing the dilator through 
and into that canal. The removal of the dilator is followed by the 
insertion of the intravaginal finger into the pus cavity. The lumen of 
the tube between these perforations should be obliterated by ligating, 
or simply dividing off and everting it. This is readily done by making 
two openings, one a little above the other (Fig. 227), and each long 
enough to permit the passage of a tube of similar size through it. The 
forceps is then passed through each opening (Fig. 228), the end of 
the tube is folded over and seized, and the tube is drawn through 

itself (Fig. 229). The result is 
that we have practically two 
tubes, one opening upon one side 





Fig. 228. — " The forceps is then passed through 
each opening." — Reed. 



Fig. 229. — " . . . and the tube is drawn 
through itself." — Reed. 



and the other opening upon the other side of a septum (Fig. 230). Thus 
made, the tube is carried through the inguinal opening, through the 
opening in the cul-de-sac, and out through the vagina (Fig. 231). The 
drainage tube should be kept from dropping too far into the wound, and 
from thus coming out through the vagina, by carefully inserting a safety 
pin through one side of the tube at a point corresponding to the cutane- 
ous surface. The superficial incision may then be closed, except so 
much of it as is required for the accommodation of the tube. 

Abdominal and abdominovaginal incisions are practised for the 
purpose of abdominal drainage in cases in which the purulent accumu- 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 545 



lation is situated behind the peritoneum, 
and is so large that the latter is pushed 
above the brim of the pelvis to such an 
extent as to permit the fixation of the 
peritoneal sac to the margins of a median 
abdominal incision. When this incision 
has been made and the abscess sac is 
found thus presenting, and it has been 
determined to practise drainage, the peri- 
toneal surface of the sac should be fixed 
either by a few interrupted sutures or a 
single continuous suture at the peritoneal 
margin of the abdominal incision. After 
it has been thus fixed, an aspirator needle, 
(Fig. 232) or a small curved trocar may 
be inserted and a large quantity of the con- 
tained pus drawn off. After this has been 
done, the cavity should be opened by an 
incision, inserting the finger for the pur- 
pose of careful exploration of the inside. 
The pus should then be washed out and 
the cavity should be treated as indicated in the preceding paragraphs. 
If it is deemed desirable to practise through-and-through drainage, 
as is the rule in the majority of cases, the tube, already described, 
may be inserted (Fig. 233) by observing precisely the same pre- 




Fig. 230. — - The result is that we 
have practically two tubes, one 
opening upon one side and the 
other upon the other side of a 
septum." — Reed (page 544). 




Fig. 231. — " Thus made, the tube is carried through the inguinal opening, through the open- 
ing in the cul-de-sac, and out through the vagina." (The uterus is cut away in the 
drawing, the left tube being shown.) — Reed (page 544). 



546 



A TEXT-BOOK OF GYNECOLOGY 



cautions as already indicated. (See Inguinal and Inguino-vaginal In- 
cision.) 

Rectal puncture was devised by the elder Byford as a method of 
election in those cases in which purulent accumulations seemed to 
press into and point toward the rectum. In certain of these cases 

a digital exploration of the rectum will indi- 
cate a soft fluctuating point. Byford in- 
serted an aspirator needle at this point and 
drew off the pus, and in certain cases even 
went to the extent of making a more pal- 
pable puncture. It was a convenient point 
of drainage and, contrary to what may be 
imagined, did not result in the formation of 
a faecal abscess or fistula. When, however, 
the latter accident did occur, as has hap- 
pened in a surprisingly limited number of 
cases, it proved to be so embarrassing as to 
seriously militate against the expediency of 
the operation. It is now but rarely adopted. 
Aspiration may be considered as a means 
of evacuating to a certain extent an accu- 
mulation of pus, rather than as a means of 
drainage; for the moment the needle is 
withdrawn the escape of pus is discontinued. 
It may be used, however, with a degree of 
safety through any of the avenues of ap- 
proach at the most presenting point of a 
pelvic abscess. 

Conservative Operations on the Tubes. — 
The indications for conservative operations 
on the tubes are more limited than in the 
case of the ovaries, since the main object 
aimed at is to favour conception. Hence 
the preservation of portions of the tubes im- 
plies that the uterus and one or a part of one ovary are left, otherwise 
the tubes would be useless. 

There can be little room at the present day for discussion as to 
the propriety of not sacrificing the internal generative organs entirely 
unless they are hopelessly diseased; for experience has proved that, 
even when marked pathologic changes are present, recovery may take 
place without impairment of function, as shown by the persistence 
of menstruation and the occurrence of conception. Surgeons are now 
most concerned with the question of the limits of conservatism, in 
which there is much room for the exercise of the individual judgment. 
The objections urged against the preservation of portions of dis- 
eased tubes, are the immediate risk of septic infection, subsequent exten- 
sion of the disease requiring a secondary operation, and the probability 




Fig. 232. — Aspirator (page 545). 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 547 

of the reforming of fresh adhesions. Most important of all, from the 
patient's standpoint, is the possibility that pain may be only tempo- 
rarily, or not at all, relieved. These points the surgeon must consider 
at the time of the operation, being guided in his decision by the history 
of the case, the extent of the disease, the result of the bacteriological 
examination of fluid retained within the tubes, and, above all, by the 
expressed wishes of the patient, assuming that she is of an age when 
child-bearing is still possible. In general it may be stated, according 
to Coe, that when the operator feels reasonably sure that no extra risk 
will be entailed, a portion of one, or of both tubes should be left. 




Fig. 233. — " If it is deemed desirable to practise througli-and-tkrougk drainage, 
already described, may be inserted.' 1 — Eeed (page 545). 



the tubt 



The simplest conservative procedure consists in liberating adherent 
tubes by gently separating all adhesions, beginning at the distal end 
and working upward with the fingers or blunt-pointed scissors, toward 
the uterus, care being exercised not to tear the delicate fimbriae (Fig. 
234). The tube and mesosalpinx must be entirely freed, straightened, 
and brought up to the normal position. A fine probe should then be 
passed down to the uterus, great gentleness being necessary to avoid 
a false passage. If the tube tends to prolapse, it is well to fix it to 
the ovary with one or two catgut sutures, which should include the 
serous coat, at a point near the fimbriated end. Fixation of the latter 
to the surface of the ovary so as to occlude the lumen, may result in 
the formation of a tubo-ovarian cyst. 






548 



A TEXT-BOOK OF GYNECOLOGY 



The distal opening of the tube may be closed either by adhesions, 
or by the rolling in and agglutination of the fimbriae without enlarge- 
ment of the tube. The septum is laid open by radiating incisions with 
scissors, and the mucous membrane is united to the perineum with 

two or three interrupted 
sutures of fine silk or cat- 
gut. If fluid escapes on 
opening the tube, the sur- 
geon must regulate his 
procedure according to its 
character. Blood or serum 
fluid may be evacuated by 
gently stripping the tube 
toward its distal end on a 
pad. Should pus be pres- 
ent, it may still seem ad- 
visable to save one tube, 
especially if the bacterio- 
logical examination shows 
that it is sterile, and if it 
is necessary to remove the 
other. After squeezing 
out the pus the tube is 
syringed out with normal 
saline solution, then with 
pure peroxide of hydro- 
gen, and finally with salt 
solution. The tube is 
catheterized and restored 
to the pelvis, being su- 
tured in its normal posi- 
tion. 

When the outer third 
or half of a tube is dis- 
eased, it is divided straight across with a scalpel, bleeding points being- 
caught with forceps. The stump is catheterized and the end slit upon 
two sides; the mucosa is then sutured to the serous covering as before. 
The end is then attached to the surface of the ovary in such a way 
that it can not become occluded. If the tube is generally thickened 
or nodular, and is strictured in its middle third, the same procedure 
is applicable, or the strictured portion may be excised and end-to-end 
anastomosis performed, as in resection of the intestines. 

Tubal abscesses adherent in Douglas's pouch are treated like other 
collections of pus in the pelvis — by vaginal incision, irrigation, and 
drainage. Kelly has suggested the treatment of such cases by the intra- 
peritoneal method, by opening and cleaning the pyosalpinx, dropping 
the tube back into the pelvis and draining per vaginam. The same con- 




Fig. 234. — " The simplest conservative procedure con- 
sists in liberating adherent tubes by gently sepa- 
rating all adhesions." — Coe (page 547). 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 549 

servative treatment is applicable to cases of tubal abortion in which the 
opposite tube must be extirpated on account of extensive disease. (See 
Surgical Treatment of Sterility.) 

The radical treatment of suppurations of the Fallopian tubes con- 
sists in the removal of the affected tube or tubes; and, when the infec- 
tion has extended to the ovaries and produced destructive changes in 
those organs, they, also, are removed. 

Salpingectomy. — While, according to Doleris, salpingitis is not a 
recently discovered disease, having been described by Spronius and 
mentioned by Morgagni in his thirty-eighth letter, its surgical treat- 
ment has been a matter of but recent development. It is curious to 
note, however, that according to Schlesinger (Centralblatt filr Gyna- 
kologie) a successful laparo-salpingotomy was performed in Russia in 
1784. Dr. Seydel was the operator and the patient was a woman aged 
forty-two, the mother of three children, and had aborted two years 
previously to the disease which required the operation, viz., a small, 
round, and firm tumour observed in the summer of 1783. It was situ- 
ated on the right side of the abdomen, and in size and consistence bore 
some resemblance to the uterus in the third month of pregnancy. The 
tumour grew visibly, especially during the courses, was accompanied by 
very violent pains, and finally reached the size of the head of a two-year- 
old child, at the same time becoming evidently softer. Vaginal exami- 
nation showed that the tumour was connected with the uterus by a 
round and firm pedicle. In the winter of the same year the catamenia 
changed in type, while the pains occurred also in the intermenstrual 
period. The author explained to his patient (a student at his course 
for midwives) that he believed the right ovary to be diseased and, in 
his opinion, not to be curable without operation. The patient, though 
informed of the risk of the operation, consented. 

The operation was performed on February 21, 1784, in the town 
of Sarepta, situated in the government of Astrakhan. The patient 
was prepared with baths, some doses of light laxatives and Peruvian 
bark; before the operation she received a small quantity of tincture 
of opium and saffron, syrup of white poppy, and Hoffmann's drops. 
After dividing the external abdominal coverings and the muscles in a 
line drawn from the umbilicus to the right inguinal region across the 
middle of the tumour, the author severed the peritoneum with a button 
bistoury, guided by the finger; three arteries were ligated; the pro- 
truding intestines were crowded back into the abdomen by means of a 
napkin soaked in warm milk; the spherical tumour, which was in- 
closed in a thick, firm capsule, and contained a fluctuating fluid, was 
connected with the uterus by a pedicle, and its upper limit reached the 
crest of the ilium; on the posterior and lower surface of the tumour 
the greatly enlarged fimbriae of the tube were perceptible. The lower 
and lateral surfaces of the tumour were so closely adherent to the ad- 
joining muscles and organs that it could not be isolated as desired; the 
author, therefore, concluded to open it. This having been done by a 



550 A TEXT-BOOK OF GYNECOLOGY 

long incision, there exuded a thick, sticky fluid, without odour, and of 
chocolate colour, weighing one pound and a half. Careful examina- 
tion proved beyond doubt that the author had to deal with a tumour 
of the tube and not of the ovary: " Qua quidem investigatione certo et 
indubitato cognovi tumoris hums sedem non ovarium fuisse, sed 
tubam." A decoction of Peruvian bark and a solution of myrrh were 
then poured into the 'cavity of the tumour, and a wad of charpie soaked 
in Balsamum Arcsei was placed in the wound of the wall of the tumour. 
After the intestines had been isolated from the parietal peritoneum 
by pieces of linen dipped in oil of rose, the author bandaged the ex- 
ternal abdominal wound with plaster and linen, but subsequently closed 
it by " suturge cruentae." 

This operator seems to have been a man of keen surgical intuitions, 
for nothing else would have prompted him to undertake the operation, 
while his subsequent conduct of the case made him a prophet of the 
latter-day canons of surgery. In the first few days after the operation, 
he endeavoured to secure a free outflow of the fluid which showed a 
tendency to form in the tumour cavity, to accomplish which he had 
recourse to tents; these proved inefficient and he used a silver tube, 
which likewise proved inefficient, when the zealous surgeon with his 
mouth to the wound sucked the foetid fluid from the cavity. He re- 
peated this operation four times daily, the patient being directed to 
lie in the interval with her abdomen turned downward to favour 
drainage. The fever was thus kept down, the purulent secretion gradu- 
ally diminished, the odour vanished, the wound contracted, and the 
patient recovered. 

The scientific recognition of these morbid states and their treat- 
ment by ablation of the uterine appendages is due, however, to the 
masterly genius of the late Lawson Tait. In contributing this knowl- 
edge to science, this great surgeon conferred upon womankind a boon 
equal to that of ovariotomy itself. This achievement, among the 
many which stand to his credit, is of itself sufficient to entitle his name 
to a place upon the scroll of immortality. That the operation has 
been abused, does not militate in the least against its intrinsic worth, or 
against the fact that it is annually the means of restoring to life and 
health thousands of women whose untimely death could not otherwise 
be averted. It was Tait who first insisted that pus in the pelvis was 
subject to precisely the same laws of surgical treatment as pus in any 
other accessible portion of the body. This axiom, the acceptance of 
which was strenuously resisted by many who were manifestly unfa- 
miliar with the technique necessary for carrying it into execution, has, 
in the twenty-five years which have elapsed since it was first enun- 
ciated, been accepted by the entire medical profession. To-day there are 
no dissenting voices. The extirpation of the uterine appendages, how- 
ever, places beyond hope of redemption the loss of the reproductive 
function. This is always a matter of serious moment, and is a result 
to be avoided whenever possible. The beneficent impulses of the 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 551 

medical profession have naturally become active in efforts to avert the 
extreme destruction induced by a naturally destructive disease. Efforts 
are, therefore, being made to conserve the organs and to perpetuate 
their functions. This conservative tendency, however, is not in con- 
travention of the law of Tait, for the elimination of pus and the arrest 
of infection are just as much aimed at by conservative as by radical 
measures. There is a strong probability that the efforts at conservatism 
have thus far resulted in a larger proportion of failures to arrest the 
infectious processes, than is to be attributed to the radical operation; 
while the restoration of function, particularly as it relates to con- 
ception, while realized in but a small number of cases, must stand 
as the vindication of efforts to save the tubes or the ovaries in whole 
or in part. The present tendency and the present necessity, as stated 
by Coe, are, not so much to ascertain the limitations of the radical 
operation, as to determine just when the recognised conservative 
method should, and should not, be applied. It may be taken as a rule 
to which there are but few exceptions, that a tube that is the seat of 
infection resulting in purulent accumulation, associated with occlu- 
sion of both the uterine and distal orifices, is not amenable to any other 
treatment than that of extirpation. The exceptions to this rule, if 
there are any, can not be determined before operation. It has not yet 
been demonstrated that fimbriae that have been curled inward and 
sealed by plastic exudation, have ever afterward become spontaneously 
disentangled with the restitution of the tubal orifice; nor has it ever 
been demonstrated that a Fallopian tube thus sealed can, without sur- 
gical intervention, again subserve the purposes of an oviduct. Con- 
servative measures, such as drainage, may conserve the structural in- 
tegrity of the tube, but they can not be expected either to restore or 
to perpetuate its functions. The conservatism thus practised must, 
therefore, have its distinct limitations. The expediency of conserving 
a functionally useless structure, which thereafter can be potent only 
for mischief, is open to serious question. The restoration of tubes 
which have been the seat of former infection may be undertaken as 
an operation of election in cases of sterility, in which the re-establish- 
ment of the reproductive function is a matter of extreme necessity. 
(See Operative Treatment of Sterility.) 

Tait's operation for removal of the Fallopian tubes, as practised by 
Tait himself, included the removal of the ovaries, and is known as 
abdominal salpingo-odpliorectomy. There were several reasons why the 
procedure was made thus comprehensive. In the first place, the ovaries 
were generally found to be the seat of disease sometimes as active 
and as destructive as that in the tubes themselves; in the next place, 
an ovary without a tube is useless for reproduction; in the third place, 
an ovary left in position may subsequently become the seat of neo- 
plastic or degenerative changes, if not of infection, and thus be a source 
of danger to the patient; and, finally, the ovary could be removed 
with the tube without adding to the hazard of the operation. These 



552 A TEXT-BOOK OF GYNECOLOGY 

reasons seem cogent enough and are yet to be recognised as having 
extreme weight. Bland Sutton and others, however, have insisted with 
reason upon the importance of leaving a healthy ovary or a part of 
an ovary in situ, to avert the neurotic storms which attend the sudden 
precipitation of the menopause, following the complete ablation of the 
appendages. This innovation, however, does not modify to any im- 
portant degree the essential technique of the operation. 

The patient is prepared and the incision is made in accordance 
with the directions already given (see Abdominal Section). As soon 
as the abdominal cavity is opened, the patient being, during the entire 
operation, in the dorsal recumbent posture, the surgeon introduces one 
or two fingers, permitting their palmar surface to glide down the 
parietal peritoneum over the collapsed bladder to the fundus of the 
uterus. This is the important landmark from which subsequent ex- 
ploration of the pelvis is to be made. Feeling to one side of the 
uterus, the condition of the Fallopian tube and of the ovary upon that 
side is thoroughly ascertained. Going back to the fundus of the uterus 
and exploring the other side, the other tube and ovary are likewise 
examined. It is sometimes difficult to outline these structures, as in 
the presence of a recent inflammatory exudation, or, in the presence 
of old and firm adhesions, the identity of tubes and ovaries may be 
lost in an apparently homogeneous mass. The next step should con- 
sist in a search of what Joseph Price so aptly designates as a point 
of cleavage. As soon as this is found, one finger should be used to 
gradually and firmly, but gently enucleate the inflammatory mass from 
the parietal peritoneum. In conducting this manipulation it is im- 
portant, first, to have obtained a correct idea of the approximate loca- 
tion of the diseased tube. It generally occupies a position behind the 
posterior fold of the round ligament, or even in the cul-de-sac of 
Douglas, but it may be found lying between the uterus and the bladder, 
or attached to the omentum, or, as in one of Eeed's cases, to the meso- 
colon {Cincinnati Lancet-Clinic). Care should be taken — especially 
in acute cases associated with high temperature — to avoid rupturing 
the pus sac and thus bathing the peritoneum with the virulent ele- 
ments of infection. This accident may be guarded against by previously 
packing the pelvic cavity with a gauze napkin, which should be so 
arranged as to prevent the dissemination of the pus. When the tubes 
have been peeled out of their nests, first one and then the other should 
be brought up into the abdominal incision. The pedicle formed by 
the ovarian ligament and the broad ligament is next transfixed by 
passing through the broad ligament a needle loaded with the ligature. 
Tait employed what is called a Staffordshire knot. This consists in 
bringing the loop of the ligature back, over and around both the tube 
and the ovary; the looped end is then placed between the free ends of 
the ligature and drawn tight; the free ends of the ligature are then 
securely tied by a surgeon's knot and are cut, leaving not less than 
half an inch beyond the knot. In applying this ligature, care is taken 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 553 



to have it impinge on the tube at its uterine juncture and to have 
it encircle the ovarian ligament. The tube and ovary are then cut 
away by scissors, care being taken to leave enough of the pedicle to 
prevent the slipping of the ligature. In certain of these cases the en- 
gorged mucosa will obtrude from the pedicle, in which case it should 
be cauterized by passing a probe, previously immersed in pure car- 
bolic acid, into its lumen. The appendages on the other side, if dis- 
eased, are treated in a similar way. The toilet of the peritoneum is 
now made. This, as practised by Tait, consisted in flushing the peri- 
toneal cavity, or more properly the pelvic cavity, with pure boiled 
water. If there was any oozing or if a pus tube had been ruptured, 
Tait inserted a glass drainage tube. This consisted of a piece of glass 
tubing long enough to reach from the cutaneous margin of the ab- 
dominal incision to the floor of the cul-de-sac; it had a number of 
small perforations in the lower 2 or 3 centimetres of its wall, and 
it was made to flare slightly at the top. Through this drainage tube, 
blood and serum was pumped by means of a suction apparatus, at in- 
tervals varying from 
half an hour to an 
hour until oozing 
ceased. The abdo- 
men was then closed 
by interrupted su- 
tures, Tait using silk 
both for the pedicles 
and for the abdom- 
inal incision. Tait's 
dexterity in perform- 
ing this operation 
was the marvel of 
surgery in his day. 
His technique is to- 
day religiously fol- 
lowed by many of the 
most eminent and 
successful operators. 

Modifications of 
Tail's operation have 
altered its technique 
to a slight degree 
without in the least 
modifying its princi- 
ple. Thus, the Tren- 
delenburg position is 

largely employed. The ovaries are now occasionally left in situ, the 
diseased tubes alone being removed — a line of practice which is yet dis- 
tinctly in its experimental stage. A hydrosalpinx is now occasionally 




Fig. 235, 



-" . . . Draining per vaginam . . . by gauze is gen- 
erally preferred." — Reed (page 554). 



554 



A TEXT-BOOK OF GYNECOLOGY 



incised, drained, and dropped back — a method of treatment that yet 
awaits justification. In ligating the pedicle, but few operators now em- 
ploy the Staffordshire knot, those who still cling to the en masse method, 
preferring to use that known as the figure-of-eight ligature. Many 
operators, however, prefer to control the ovarian artery primarily by 
snap-forceps, and then, after cutting away the ovary and the tube, to 
ligate the vessel, with its associated veins, individually; the peritoneal 
folds of the broad ligament being sutured over the ligated extremities of 
the vessels. Catgut is now very generally employed instead of silk for 
both ligatures and sutures. Drainage, in the presence of assured hemo- 
stasis, is but rarely employed, and when it is, Martin's method of open- 
ing the floor of the cul-de-sac and draining per vaginam, either by a 
self-retaining tube or by gauze, is generally preferred (Fig. 235). In 
the presence of persistent oozing, a gauze pack is sometimes adjusted 




Fig. 236. — "In the presence of persistent oozing, a gauze pack is sometimes adjusted." — Keed. 



(Fig. 236). The toilet of the peritoneum is now generally made by 
means of pieces of dry sterilized gauze, by which the cavity is mopped 
out. The abdominal incision is now closed by many operators by means 
of the laminated suture. (See Abdominal Section.) 

Abdominal panhysterectomy has been adopted by many operators 
(Fig. 23?) for the radical treatment of purulent infections of the 
uterus and adnexa. The technique does not differ in any particular 
from that already described. (See Abdominal Panhysterectomy.) 

The reasons for adopting this operation are practically those which 
prompted Doyen, Pean, Segond, and the French school in general, 



TREATMENT OP INFECTIONS OP THE FALLOPIAN TUBES 555 

to adopt vaginal hysterectomy in these cases. In the first place, in 
certain of the infections, notably that by the streptococcus (see Strep- 
tococcals Infection of the Uterus), the parenchyma of the uterus is 
invaded, with the result that more or less permanent changes are estab- 




Fig. 237. — '' Abdominal panhysterectomy has been adopted by many operators 

(page 554). 



-Reed 



lished; even in cases of gonococcous infection, in which the patho- 
logic changes have been manifested in the deep utricular glands and 
in the muscular stroma with which they are surrounded, hyperplasias of 
a more or less permanent character are established. These are the 
cases which furnish the distressing examples of persistently pain- 
ful uteri following ablation of the appendages. It is to be acknowl- 
edged that the removal of pus tubes does not restore many of these 
cases to even symptomatic health. In many cases an infected uterus, 
in spite of repeated curettage, remains an infected uterus after the 
removal of the diseased appendages. For this reason the French school 
of surgeons, with practical unanimity, has adopted the practice of 
removing the diseased uterus with the diseased adnexa. The results 
have justified the practice. According to the observation of Eeed, 
the primary surgical recovery from this operation is more uniform 
and attended with fewer embarrassing incidents than that following 
the ablation of the appendages. The choice between panhysterectomy 
and supravaginal amputation in these cases rests upon no debatable 
ground. If the operation is undertaken because of infection of the 
uterus, it would be manifestly improper to leave a part of that in- 
fected organ in situ, particularly when its complete removal can be as 
easily and as safely effected. Eeed prefers the abdominal to the vaginal 
section, for the reason that it places all possible complications under 
more complete control. Doyen admits that abdominal section is the 
operation of choice in the presence of large adnexal tumours and also 
of probable tuberculous peritonitis. Pryor, with equal frankness, 
acknowledges that vaginal ablation should not be attempted in the 
presence of complicating intestinal lesions. In these acknowledgments 



556 A TEXT-BOOK OF GYNECOLOGY 

are found important limitations of the vaginal method, and equally 
important reasons why the operation should be done by abdominal 
section. The frequency with which unsuspected adhesions between the 
tubes and the intestines are encountered, and the known impossibility 
of diagnosticating all, or even a majority of these cases, before explora- 
tory incision, constitutes sufficient reason for invading these cases from 
above. The remoteness, in an anatomical sense, of many of these com- 
plications renders impossible their detection by vaginal exploration. 
Eichelot, a former partisan and present friend of vaginal hysterectomy, 
states {Annals of Gynecology and Pcediatry) that in 1 out of every 
2 cases in which he did vaginal exploratory incision, he found con- 
ditions which rendered the other route more desirable, and that he 
consequently had occasion to regret his diagnostic ability, but " to- 
day," he adds with captivating naivete, " I no longer have any regrets, 
because total abdominal hysterectomy gives me complete cures." 
Miller (Bulletin of the Johns Hopkins Hospital) concludes, after a care- 
ful bacteriological examination of 68 uteri removed by operation, that 
" in uncomplicated cases of hystero-myomectomy, hysterectomy for 
inflammatory cases or ovarian tumours, in operations for extra-uterine 
pregnancies, and in all such cases where the vagina and cervix were 
normal except probably for invasion by the gonococcus, the safest 
route so far as infection is concerned is the abdominal." Miller, how- 
ever, fails to explain why invasion by the gonococcus should be made 
an exception. Zweifel employs the abdominal method of complete 
hysterectomy, and in 65 of his cases, studied by Abel and reported 
in 1894, both the primary and ultimate results were uniformly satis- 
factory. Fritsch, Martin, and Jacobs, object to the retention of the 
cervix or any part of it in hysterectomy for infections involving the 
uterus and appendages, urging as a reason for their position, that the 
cervical mucosa, however carefully treated, may act as the nidus of 
infection, which, under such circumstances, may and frequently does 
invade the field of operation. 

Doyen's operation for infections of the Fallopian tubes consists in 
a vaginal hysterectomy including the removal of the Fallopian tubes 
and the ovaries with the uterus. The operation was first done for this 
purpose in 1887, although Doyen had previously adopted practically 
the same technique for nonsuppurative diseases of the appendages. 

The operation is performed by placing the patient upon her back 
with her knees well flexed, when the perineum is retracted and the 
cervix is seized with a strong forceps, one forceps being applied to 
each lateral lip. The cervix is now drawn down by firm traction and 
an incision is made in the posterior cul-de-sac by means of curved 
scissors, a bistoury never being employed. The peritoneum, if free, 
is opened by the second or third cut of the scissors, permitting the 
escape of a few grammes of normal peritoneal fluid. The right index 
finger is now introduced into the serous button-hole for the purpose of 
exploring the posterior surface of the uterus and that of the append- 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 557 

ages. If adhesions are found to exist in a moderate degree, they are 
broken up so far as they can be reached. This preliminary explora- 
tory incision is insisted upon as an essential part of the technique, and 
as the means by which it is to be determined whether to conclude the 
operation by the vaginal route or to make an abdominal section. The 
condition of the proximal serous surfaces, the fundus of the uterus, 
the sacto-salpinx if it exists, and the ovaries, may thus be readily 
explored. If the cul-de-sac is obliterated by inflammatory adhesions, 
the latter may be broken up by passing the finger with its palmar 
surface to the uterus. The exploration of the true pelvis being com- 
pleted, and fluid accumulations being evacuated, it is easy to determine 
whether or not to complete the operation. The radical operation being 
decided upon, the cervix is drawn downward and backward, a short- 
bladed retractor is introduced anteriorly, and the circum-cervical in- 
cision is completed with the scissors. The bladder is separated with 
the right index finger as high and as far to either side as possible. The 
uterus is then isolated before and behind from any neighbouring organs 
to which it may be attached. The neck is drawn down near the vulva, 
when, with scissors, the anterior wall is split from the cervix to the 
anterior peritoneal cul-de-sac. This now comes into view and is freely 
divided, after which the median semisection is carried to the fundus 
of the uterus. At this stage a loop of the intestine, of the omentum 
or the sigmoid, or sometimes of the vermiform appendix, may be found 
adherent to the uterus, or may be drawn down beneath the retractor. 
If this is found to be the case, the isolation of the fundus of the uterus 
is easily made under vision. The body of the uterus is easily everted, 
the cervix hanging over the fourchette. The appendages on both 
sides are now explored with the index finger and their extirpation 
can be undertaken, beginning upon either side, at the choice of the 
operator. It is well to begin by utilizing the index finger to break 
down any remaining adhesions, after which the tube and ovary may 
be readily drawn down by moderate traction, after being seized by the 
index and little fingers. If there are serous cysts, or if the purulent 
accumulations are too large, it is easy to evacuate them in the course 
of the manoeuvres. It is exceptional when the extraction of the 
adnexa by this manipulation is not complete. A clamp is then applied 
above and below to each broad ligament ; a smaller clamp being applied 
outside each larger clamp, to prevent the retraction of the pedicle. 
Care should be taken, in applying the small forceps, to seize the 
uterine and ovarian vessels respectively. Doyen .removes the large 
clamps at the end of four hours and the smaller ones after ten hours. 
The sterilized gauze with which the vagina is packed up to the peri- 
toneum, is permitted to remain in situ until the third or fourth day. 
Beginning on the fifth day, unless sooner indicated, vaginal injec- 
tions are practised to the extent of five or six every twenty-four hours. 
Modifications of Doyen's operation have been adopted by various 
operators. Pean commenced the operation by isolating the cervix from 



558 A TEXT-BOOK OP GYNECOLOGY 

the vaginal mucosa and by applying hemostatic forceps to the uterine 
arteries on each side. He divided the cervix bilaterally, thus forming 
an anterior and a posterior flap; these were then seized by a fresh grip 
of the volsella, by which progressive traction was exercised upon the 
uterus. As the organ was dragged down, the lateral tissues were seized 
by hemostatic forceps and the lateral incisions of the uterine wall were 
carried step by step to the fundus. The obvious objection to this 
method is the absence of the preliminary exploration practised by 
Doyen, and the use of a large number of useless clamps to encumber 
the field of operation and to render difficult that which ought to be 
easily accomplished. Pryor, who has done more than any one man to 
introduce the vaginal method of operation in America, has adopted 
several important innovations. He utilizes the procedure of Landau 




Fig. 238. — Pryor " has invented and employs a very valuable traction forceps." — Reed. 

in making complete semisection of the uterus — i. e., dividing not only 
the anterior wall, as does Doyen, but the posterior wall also. He has 
invented and employs a very valuable intrauterine traction forceps 
(Fig. 238). 

For splitting the uterus, he uses large curved grooved directors, 
one being passed above and behind the uterus anteriorly, and another 
posteriorly, care being taken that no fold of intestine or of omentum 
is caught between this director and the uterus. A probe-pointed, 
slightly curved bistoury is now used for dividing the uterus, the blunt 
point following the groove in the directors. First, one half of the 
uterus with its adnexa is drawn down, and the broad ligaments are 
secured by clamps, in the application of which great care is exercised. 
One clamp is applied to the upper margin of the broad ligament, and 
is locked with its point embracing about the upper half of the ligament, 
care being taken that the ovarian artery is included in its grip; the 
other forceps is applied to the lower half of the broad ligament, care 
being taken that the uterine artery is embraced within its grip. In 
this way the broad ligament folds upon itself without injury. The 
pelvis is now packed with sterilized gauze pads secured by strings with 
which to facilitate their removal. Le Bee ligates the pedicles and draws 



TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 559 

them down into the vagina; and, in cases in which there is no probable 
remaining infection of the pelvic cavity, the ends of the broad liga- 
ments are drawn together on the median line, thus closing the peri- 
toneal cavity. 

The indications and limitations of Doyen's operation should be 
understood. The raison d'etre of the operation is the fact that the 
results following ablation of the appendages are not always satisfactory. 
This depends upon permanent changes in the muscularis of the uterus 
and in its lining membrane, causing the organ to be persistently painful 
after the removal of the diseased adnexa. In the presence of acute 
streptococcous infection of the uterus and the Fallopian tubes, the indi- 
cations for complete ablation are positive; while in the presence of long- 
standing chronic infection of both the uterus and the tubes the indica- 
tions are almost equally strong. In many cases belonging to the 
latter class, the uterus not only remains painful, but is a persistent 
fons et origo of a purulent discharge which can not be controlled even 
by repeated curettage. The result is a failure to restore the patient 
to health. The preservation of the now functionally useless womb is 
no argument against the operation. The procedure, however, has its 
limitations. Eichelot, while personally preferring vaginal hysterec- 
tomy, recognises its limitations and practises abdominal panhysterec- 
tomy. Doyen says that abdominal section is indicated in the presence 
of large tumours of the adnexa and in the presence of probable tuber- 
culous peritonitis. Pryor concludes that vaginal ablation should not 
be attempted through a vagina so narrow as to necessitate incision of 
the perineum, as practised by Segond. He also states that, in the 
presence of complicating intestinal lesions, the latter are to be recog- 
nised as the principal indication for intervention, which under these 
circumstances, should be done exclusively by abdominal section. He 
fails to state, however, just how these complications may always be 
recognised. The personal preference of the operator, and his familiar- 
ity with a given technique, must alwa} r s be recognised, however, as a 
cogent reason for its employment. 



CHAPTER XXXYI 

MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES 

Malformations: Absence; rudimentary development; accessory ovaries; coexist- 
ence of ovaries and testicles — Displacements : Descensus ; prolapsus ; hernia. 

Malformations of the Ovaries. — Since the ovary, like the testicle, 
begins its development at a higher level in the abdomino-pelvic cavity 
than that which it ultimately occupies, cases occur in which its descent 
has been arrested, and in which it is found, in the adult, above the 
plane of the pelvic brim. Since, further, the ovary, unlike the testicle, 
does not normally pass into the inguinal canal, it must be counted as 
a displacement when it is met with in that canal, or beyond it in the 
substance of the labium majus. The ovary, also, is liable to malforma- 
tions by defect and by excess. 

Absence of the Ovary. — Complete absence of both ovaries in an 
individual furnished with a uterus and external genital organs of the 
female type, must be regarded as an almost undemonstrated occurrence. 
For its demonstration, it would be necessary to examine post mortem, 
not only the pelvic cavity, but also, and with great thoroughness, the 
abdominal cavity as well. Its occasional occurrence in grossly de- 
formed foetuses is, however, beyond doubt. The absence of one ovary 
is not so uncommon, and, when met with, is usually associated with 
defect of the corresponding Miillerian duct (absence of the Fallopian 
tube, uterus unicornis, and unilateral vagina), and sometimes with ab- 
sence of the corresponding kidney (as in the case reported by Dela- 
geniere, Progres medical, 2. s., vol. xx, p. 256, 1894). 

Rudimentary State of the Ovary. — Although actual absence of the 
ovaries may be one of the extreme rarities of teratology, functional 
absence (i. e., their rudimentary state) is a well-established and not 
very uncommon maldevelopment. The glands may be so ill-developed, 
and may show such an approximation in their microscopical characters 
to the appearances seen in the earliest period in intrauterine life, that 
it may be difficult to decide from their examination alone whether they 
are ovaries or testicles. In form they may resemble the foetal or in- 
fantile type, and they may be associated with the foetal, the infantile, 
or the bicornate uterus. Further, they may coexist with other an- 
omalies such as rudimentary tubes, stenosis of the aorta, and hypo- 
plasia of more distant organs. Eudimentary development is also often 
combined with congenital displacement, which is indeed itself a form 
560 



MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES 561 



of rudimentary development. If one ovary alone is in a rudimentary 
state, the anomaly may not appreciably influence the reproductive life- 
history of the individual in whom it exists: but if both glands are 
imperfect, the menstrual flow is either entirely absent, or is imperfectly 
established, there is defective hirsute development on the mons veneris, 
there is absolute sterility, and there is a condition of general infantil- 
ism with or without chlorosis and vascular hypoplasia. Cases have, 
however, been put on record, in which the rudimentary state of the 
ovaries has been associated with a normal development of the uterus 
and with all the signs of general bodily and mental vigour, and even 
with indications of sexual desire. The diagnosis of the anomalous con- 
dition of the genital glands may be made provisionally from a con- 
sideration of the symptoms, but with certainty only by means of a 
laparotomy. Manifestly, if it exists in association with rudimentary 
development of the uterus, it will be of little use to spend time and 
energy in therapeutical efforts directed against the latter organ. "Where 
acute menstrual sufferings and marked nervous phenomena of the 
nature of epilepsy and insanity exist, it may be well to consider the 
question of removal of the rudimentary ovaries: but it by no means 
follows that the nervous manifestations will cease, for they can not 
always be regarded as consequences of the ovarian defect: indeed, they 
and the defect may quite possibly be the results of a common cause. 
Rudimentary ovaries 
may be due to ar- 
rested development 
during the embry- 
onic period of intra- 
uterine life, or to 
peritonitis during 
the foetal epoch, or 
to ovaritis from the 
supervention of one 
of the exanthemata 
in childhood. 

Accessory Ova - 
ries. — With the ex- 
ception of the case 
of third ovary de- 
scribed by Winckel 
(Lehrbuch. p. 595, 
1886), no genuine 
example of duplica- 
tion of the female genital gland has been put on record, and even 
WinekeFs case is in the opinion of Nagel (in Veifs Handbucli der 
Gynakologie, Bd. i. p. 562. 1897) open to doubt by reason of the presence 
of gland ducts in the supposed ovarian body. On the other hand, 
accessory ovaries, or, as it is more correct, perhaps, to name them, " con- 




Fig. 239. — "-Constricted ovaries' are much less rare." Der- 
moid cyst in constricted portion. > — Balla>ty^e page 562). 



562 A TEXT-BOOK OF GYNECOLOGY 

stricted ovaries " (Fig. 239), are much less rare. One such ovarian frag- 
ment was seen by Ballantyne and Williams in a series of 61 consecutive 
autopsies on females dying in the Edinburgh Koyal Infirmary; it was 
as large as a pea and was made up of ovarian stroma with Graafian 
follicles; it was attached to the anterior border of the right ovary 
by a stalk consisting partly of fibrous tissue with a covering of low 
cubical epithelium, and partly of solid columns of epithelial cells 
inclosed in the fibrous tissue; and it showed a cicatrix pointing to the 
dehiscence of a Graafian follicle at some time in the life of the indi- 
vidual. As many as three accessory ovaries have been found in one 
case, and an ovary has been noted divided into two almost equal parts. 
It is supposed that the constriction of the ovarian substance is pro- 
duced by foetal peritonitis. Clinically, accessory ovaries are of im- 
portance in explaining the want of success which sometimes follows 
removal of the ovaries performed in order to induce a premature 
menopause; they also offer an explanation of the occurrence of preg- 
nancy after a double ovariotomy, and of the presence of three (or more) 
separate ovarian cystomata. 

Coexistence of Ovaries and Testicles in the Same Individual. — The 
presence of one ovary and one testicle or of two ovaries and two testicles 
in the same individual, constitutes the anomalous condition described 
as true hermaphroditism. Of the bilateral form (that in which an 
ovary and testis are present upon both sides of the body), no abso- 
lutely conclusive example in the human subject has yet been recorded; 
the two-months' old, premature, and otherwise malformed infant de- 
scribed by Heppner (Archiv fur Anatomic, Physiologie, und wissen- 
schafiliche Medicin, p. 679, 1870) had a rudimentary uterus and a 
vagina, and, on both sides, a normal ovary, parovarium, and tube, and 
near to each ovary was a body resembling a testis and containing 
tubules running toward the hilum; but whether the last-named bodies 
were really testicles, is a hard question to settle, especially as the 
drawings are unsatisfactory. Lateral hermaphroditism, which may be 
defined as the presence of an ovary on one side and a testis on the 
other, has been met with in a few cases, of which those reported by 
Obolonsky (Zeitschrift fur HeiTkunde, vol. ix, p. 211, 1888) and Schmorl 
(Archiv fur pathologische Anatomie und Physiologie, etc., vol. cxiii, p. 
229, 1888) are the most clearly established. In Schmorr's patient, an 
individual twenty-two years of age, there was hypospadias, which was 
successfuly operated upon; a swelling appeared in the groin, which was 
regarded as a degenerate testis and was excised, but death occurred. 
At the autopsy, it was found that the body in the left groin was an 
ovary, there was a uterus bicornis, and, on the right side in the scrotum 
was a testis with a rudimentary epididymis. Blacker and Lawrence 
(Transactions of the Obstetrical Society of London, vol. xxxviii, p. 265, 
1896) have described what is apparently the only genuine case of unilat- 
eral hermaphroditism (ovary or testis on one side, with ovary and testis 
on the other) in the human subject. The case was that of a foetus, other- 



MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES 563 

wise well formed, in which was found a uterus unicornis, a normal 
ovary and tube on the right side, and on the left side an ovo-testis, 
with a vas deferens and epididymis. The left gland (ovo-testis) in one 
part showed cell columns, cell nests, and Graafian follicles with a 
large quantity of stroma (ovarian portion); and in a second part ex- 
hibited an abundant stroma, with definite tubules filled with cells, 
and forming at the hilum a retelike structure (testicular portion). 
It may, therefore, be accepted that the occurrence of what may be 
termed anatomic hermaphroditism in the human subject has been 
demonstrated — that is to say, in one individual genital glands have been 
found, one of which had a structure which could be justly called 
ovarian, while the other showed appearances warranting the conclusion 
that it was testicular in nature. Xo case, however, has yet been met 
with in which functional hermaphroditism was present — that is to say, 
no individual has ever been known to possess two kinds of genital 
glands both showing functional activity. It is extremely doubtful 
whether any such association ever will be demonstrated. 

Displacements of the ovaries are of frequent occurrence. They 
may exist in any degree from a slight descensus to a complete prolapsus, 
or even a hernia. 

The anatomical connections and relations of the ovary render it 
difficult to determine the precise normal locus of the organ; attached, 
as it is, by the ovarian ligament, and resting, as it does, on the fold 
of the broad ligament, it enjoys normally a considerable range of 
mobility. This seems to be a wise provision of Xature whereby the 
sensitive organ is enabled to evade what would otherwise be painful 
pressure from neighbouring structures, such as the uterus, the caecum, 
the sigmoid, and even the overloaded bladder. The ligamentum ovarii 
proprium is firm and round, consisting of fibro-muscular elements, is 
covered by peritoneum, has a length of about 2.6 centimetres, and is 
essentially inelastic; while the duplicatures of peritoneum, which 
comprise the remaining suspensory apparatus of the ovary and permit 
that organ to ascend with the fundus uteri during pregnancy, are 
highly elastic. It is to be seen, therefore, that, to an important 
extent, the position of the uterus determines the position of the 
ovary. The ovary moves with the uterus and, to some extent, independ- 
ently of it. 

Descensus and Prolapsus. — AVhen these variations of position occur, 
however, they do not involve the establishment of either traction or 
pressure upon the organ whereby its circulation becomes mechanically 
disturbed, nor is the ovary prevented from returning within what 
may be recognised as its normal bounds and limits. There are cases, 
however, in which the organ is forced into a distinctly abnormal posi- 
tion. Thus, it is occasionally found posterior to the uterus and riding 
upon the utero-sacral fold of the peritoneum; in other instances it 
gravitates into the cul-de-sac, often becoming adherent (Fig. 240); 
in a few cases it has been found adherent between the uterus and 



564 



A TEXT-BOOK OF GYNECOLOGY 



the bladder, while in still other cases it has been found adherent to 
the intestines and drawn by them well above the brim of the pelvis. 

Uterine fibromata are frequent causes of ovarian displacement, 
the organ often becoming diseased in consequence of repeated trau- 
matisms inflicted by the 
neoplasm. 

The symptoms of pro- 
lapsus uteri include pain, 
which is generally re- 
ferred to the normal 
locus of the organ with- 
out reference to its dis- 
placed position; and, 
generally, nervous re- 
flexes of the most vague 
and indefinite character, 
with a tendency to in- 
crease in complexity and 
seriousness. The diag- 
nosis, however, must rest 
upon careful physical ex- 
ploration, under anes- 
thesia if necessary. 

The treatment should 
be addressed primarily to 
any recognised causal 
condition; thus, in the 
presence of a retro-devia- 
tion of the uterus, that 
condition is to be reme- 
died before attention is 
given to the displace- 
ment of the ovary. If the cure of the causal condition does not re- 
sult in relief of the remaining symptom and in restitution of the 
ovary to its normal position, surgical treatment should be addressed 
to the ovary itself. It may be stated as a rule to which there are 
but few exceptions, that an ovary which has acquired the habit of 
descensus can be made to remain in its normal position only by 
means of surgical fixation. This may be done in many cases by short- 
ening the round ligament by Alexander's, or preferably by Mann's, 
method. If the latter operation is selected, a suture may easily be 
passed through the utero-ovarian ligament, by which the ovary may 
be anchored in its normal position. The ovary itself should not be 
injured, even in a surgical way, unless it is the seat of disease. 

Hernia of the ovary is of occasional occurrence; it may exist at 
birth, or it may develop in old age; and it generally consists in a 
descent of the organ through the canal of Nuck, which persists in 




Fk 



240. — %t ... It gravitates into the cul-de-sac, often 
becoming adherent.'- — Reed (page 563). 



MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES 565 

many cases. It is encountered clinically as an inguinal hernia. Men- 
ciere lias reported 4 cases of hernia of the ovary occurring in children 
and has been able to find 7 others on record. All 11 were inguinal, 
9 were on the left, and 2 on the right side, and in one instance the 
uterus, as well as both tubes and ovaries, lay in the sac. 

Browne, after a careful study of hernia of the ovary, concluded 
that the condition was of more frequent occurrence than was gener- 
ally supposed. He attributes congenital hernia of the ovary chiefly 
to arrest of development during intrauterine life; and finds that it 
is always inguinal, often double, and when single, generally on the 
left side. The formation of this condition is favoured by the persist- 
ence of the canal of Xuck and by the size and shape of the ovary, 
which is at first a long flat body with its apex pointing toward the 
canal. 

The fact that, at birth, the ovaries are situated above the ilio- 
pectineal line, and descend during the first few months into the true 
pelvis, is also recognised as a contributory causal circumstance. 

Hernia of the ovary is generally associated with corresponding 
descent of the Fallopian tubes, and, as in Menciere's case, the uterus, 
too, may be found in the sac. Acquired hernia, on the other hand, 
is not always inguinal, but may occur through any ordinary hernial 
opening. The condition generally occurs with pre-existing intestinal 
or omental hernia. The condition is generally unilateral, occurring 
more frequently on the right side. Labour and the postparturient re- 
laxation of the tissues are recognised as the chief causes. 

The symptoms of ovarian hernia may be confusing from the fact 
that omentum or intestine may be present in the sac. In the con- 
genital form, this complication is less likely to occur. In such cases, 
the hernia exists as a small painful nodule, lying at the orifice of the 
inguinal canal. In consequence of the contraction of the tissues after 
the descent of the organ, the hernia is generally irreducible, any effort 
to push the tumour back being the cause of extreme and depressing 
pain, which may produce symptoms of shock. The absence of crepitus 
in the tumour, and of the usual reflex intestinal symptoms, indicates 
that the bowel is not involved in the protrusion. The tumour may, 
however, be the seat of important changes, induced either by strangula- 
tion, or by organic degeneration of the ovary. In the acquired form 
of hernia, the intestine and omentum are more liable to be found in 
the hernial sac, which, as already intimated, does not always protrude 
through the inguinal canal. One of the most perplexing forms of 
hernia of the ovary is that in which the protrusion occurs through the 
obturator canal. Yon Eogner G-usenthal describes a case in a patient 
sixty-six years old. There were symptoms of strangulation, with pain 
and indistinct gurgling, but no distinct tumour, in the right groin; 
femoral hernia was diagnosticated. On operation, the crural canal 
was clear, but a bulging was seen under the pectineus muscle. The 
muscle was divided and the sac of the hernia, in a gangrenous condi- 



566 A TEXT-BOOK OF GYNECOLOGY 

tion, bulged forward. This contained the right ovary and tube, and 
a coil of intestine, all gangrenous. 

The treatment of these cases consists in incising the hernial sac and 
extirpating the ovary, which will generally be found to have undergone 
such morbid changes as to render its return to the peritoneal cavity 
unjustifiable. In infantile cases, however, the organ may be saved 
in many instances. In 11 cases collected by Menciere, cure resulted 
in 10; in 8 by radical operation, in 2 by reduction and bandaging. 



CHAPTER XXXVII 

INFECTIONS AND INFLAMMATIONS OF THE OVARIES 

Classification: Hyperemia ; acute inflammation: chronic inflammation — Bacteria 
of the ovaries — Individual infections: Streptococcous infection; gonococcous 
infection; pneumococcous infection; Bacillus call communis infection; un- 
usual bacterial infections; tuberculosis. 

The classification and description of the inflammatory lesions of 
the ovary presents many difficulties, because, first, of a confusing nomen- 
clature; and, secondly, the ovary can scarcely be said to stand alone 
in its pathologic lesions, since its close association with the other organs 
of the pelvis, anatomically and physiologically, makes its lesions in 
a vast majority of cases only a part of a pathological picture. 

A primary statement in this chapter must correspond with that on 
inflammatory lesions of the Fallopian tubes, to the effect that all in- 
flammatory lesions of the ovary are due to bacterial infections. Only 
after such a dogmatic and sweeping statement may we qualify it by 
saying that malpositions, irritations, strangulations or new growths, 
may produce hyperemias and subsequent changes in the tissues, which 
are very closely related to those changes brought about by a long- 
continued action of the less virulent germs. In other words, the class 
containing the cases of greatest number and clinical importance is the 
bacterial, and the minor class is that which depends upon mechanical 
causes. 

Hyperemia of the ovary is a physiologic condition during men- 
struation (see Menstruation), sexual excitement, and pregnancy. In 
this connection, however, we consider only those hyperemias which 
overstep the physiologic limitations. This is exemplified, for example, 
in a case in which there exists a malposition of the ovary with twist 
of the mesovarium, thus interfering with the venous circulation; it is 
also shown in the case of prostitutes who are subjected to excessive 
natural or unnatural sexual excitement; also, inflammation in other 
pelvic organs and pressure from neighbouring tumours and pessaries, 
are among the recognised causes of this persistent excess of blood in 
the ovary. Bacterial toxines, or the germs themselves, may induce a 
hyperemia from which the essential phenomena of inflammation are 
absent. A hyperemia of this class is easily transformed into an active 
inflammation through the influence of infection by even the less 

567 



568 A TEXT-BOOK OF GYNECOLOGY 

virulent bacteria. The excessive blood supply may continue to in- 
crease, until, by sheer force of mechanical pressure, there occurs transu- 
dation of the liquor sanguinis and migration of the leucocytes. A 
hyperemia may thus become transformed into an inflammation. The 
organization of the transuded elements constitutes a true hyperplasia, 
while, as a result of the persistent excessive nutrient supply, pre-exist- 
ing histologic elements may become enlarged, thus establishing a true 
hypertrophy. In any event, the change in the stroma is such as to 
render it unyielding to the premenstrual blood pressure, this condition 
inducing extreme pain during the few days preceding the onset of the 
monthly flow. A passive hyperemia of the character herein described 
exhibits, on microscopic examination, dilated, normal vessels, well 
filled with blood, the walls of the blood vessels thickened, and some- 
times thrown into folds which project into the lumen. In some cases, 
the walls of the vessels have been found to be the seat of hyaline 
degeneration. In other cases, however, marked perivascular changes 
are noted; the stroma of the ovary may show a round-celled infiltra- 
tion, and, as already indicated, a decided hyperplasia. 

The walls of the follicles may yield to the blood pressure, the fol- 
licles themselves becoming the seat of slight hemorrhages, and their 
walls, when cut and mounted, giving the appearance of minute punc- 
tate hemorrhages. The hypertrophic changes in the stroma itself may 
interfere with the spontaneous rupture of the follicles, which, as a 
result, undergo degeneration. The most frequent consequence of 
hyperemia of the ovary is that form of hemorrhage known as hema- 
toma. (See Hematoma of the Ovary.) 

The prognosis of hyperemia of the ovary is favourable in its early 
stages and before it has resulted in marked trophic changes in the 
organ itself. When these changes have occurred, however, the condi- 
tion becomes essentially progressive. The treatment in the early stages 
may be said to be confined to efforts to remove the causative condition; 
this once accomplished, the hyperemia itself will subside. In the later 
stages, however, when the ovary has become the seat of hyperplastic 
and hypertrophic changes, and, particularly, when the follicles have 
undergone degeneration, the condition is irremediable by any other 
means than ablation of the organ. (See Oophorectomy.) 

Acute inflammation of the ovary manifesting, in all of their inten- 
sity, the phenomena of vascular engorgement, circulatory stasis, tissue 
infiltration, and the migration of corpuscles, and resulting in sup- 
puration, always depends upon infection. The same may be said of 
those inflammations of the ovaries that do not result in the destruction 
of tissue — for it is to be remembered that ovarian tissue, like other 
tissues, has the power within certain limits of resisting invasion by 
micro-organisms, although the defensive effort induced by the presence 
of the germs may be productive of all the essential phenomena, short 
of suppuration itself. The resulting changes in the tissues may be 
more or less permanent, manifesting themselves in increased density 



INFECTIONS AXD INFLAMMATIONS OF THE OVARIES 569 

of the stroma, in permanent enlargement of previously distended blood 
vessels, and in organization of the inflammatory products. 

Acute oophoritis is usually the result of streptococcous infection. 
The ovary is swollen, soft, and of elastic consistence, the blood vessels 
are strongly injected, the stroma is infiltrated by serum and pus, and 
the surface of the organ is the seat of a general peritonitis which is 
accompanied by a deposit of fibrin, a pseudomembrane, and pus. The 
stroma is filled by minute abscesses, and is indurated; the undeveloped 
follicles are highly infiltrated by small round cells, and the more 
mature follicles lose their epithelium and are transformed into pus 
sacs. The sheaths of the blood vessels are infiltrated by small round 
cells. This condition may continue, to the complete destruction of 
the ovarian stroma by a fusion of abscesses; or, with the subsidence 
of the inflammation, the ovary may return to its normal size, but 
be left indurated and bound down by adhesions, and rarely retaining 
a functional value. A corpus luteum is apt to serve as a focus of 
especial activity and early abscess formation. 

The gonorrhceal infections may undoubtedly produce an acute 
oophoritis (Wertheim, Alenge) but the lesions are usually confined to the 
surface of the ovary. Abundant adhesions are formed. The follicular 
contents become turbid and almost purulent, or they may be blood- 
tinged. There is an infiltration and thickening of the stroma by small 
round cells — a lesion which has a considerable importance in the ex- 
planation of follicular cyst the result of a toughened follicular capsule. 

Chronic inflammation of the ovarian tissue manifests itself pri- 
marily in a proliferative activity in the stroma, which leads to an in- 
filtration by small round cells and the deposit of new connective tissue. 
The blood vessels will be somewhat dilated and their sheaths infil- 
trated by small round cells. The parenchyma or Graafian follicle 
will be unchanged in the early forms, but the gradually increasing 
deposit of firm fibrous tissue in both the connective tissue and muscular 
elements of the stroma, presses on, and will cut off, more and more, 
the nutrition of the follicle, to a degree of destruction which may 
range from the mildest interference to a complete obliteration of all 
specific ovarian elements. This connective-tissue change may. however, 
be limited to the surface of the organ, and, even though the Graafian 
follicle persists, it is rendered functionless by the complete encasing 
shell of the albuginea. Such ovaries may be larger than normal, cystic, 
and presenting a smooth surface; or the interstitial connective tissue 
may contract after its formation to give an organ which — smaller than 
usual — has a roughened and distorted surface, and is in reality a dense, 
new. interstitial connective-tissue ball. In the latter type of inflam- 
mation, the Graafian follicle is usually entirely absent, and the arteries 
are tortuous and have much thickened walls. In those types which 
present enlargement, many of the Graafian follicles are transformed 
into cysts of varying size and the vessels are widely dilated, especially 
the veins. 



570 A TEXT-BOOK OF GYNECOLOGY 

Chronic oophoritis is usually preceded by an acute inflammation, 
but may gradually develop as the result of long-continued mechanical 
irritation or obstruction in the blood flow. The morbid changes present 
a variety which has led to the designation of several classes of chronic 
oophoritis; but the divisions scarcely seem to be justified on a com- 
prehensive study of chronic inflammations of this organ. 

Bacteria of the Ovaries. — It can hardly be said that, as yet, there 
is any bacteriology of the ovaries as distinct from the facts and 
considerations already brought forward in reference to the Fallopian 
tubes. Yet the mode of entrance and the resulting pathologic lesions 
vary with the variety of germ present, to a degree that makes a rather 
detailed study of the bacteria concerned in ovarian infections necessary. 

The anatomic structure of the ovary, the peculiar physiologic 
activity as expressed in a periodic congestion and the rupture of a 
Graafian follicle, the liability to the development of new growth, and 
the tendency to torsion of the ovarian pedicle, lay the ovary open to 
invasion by bacteria in a way from which even the tubes are to some 
extent free. Furthermore, we must class, as predisposing causes, 
almost every inflammatory condition of the female genital tract, a 
statement given its greatest force by a mere reference to the ex- 
treme frequency of the tubo-ovarian abscess in gynecological prac- 
tice, which shows that the tubes and ovaries are often subject to 
the same bacterial ravages. This fact is further borne out by the 
statistics of Martin, which show that out of 4,948 polyclinic ovarian 
patients, 1,464 suffered from subacute or chronic endometritis, and 
834 from chronic metritis. Yet another causative factor is found in 
the fact that when new growths of the ovary, belonging to the class 
of cystoma, undergo changes such as result from torsion of the 
pedicle, they are liable to the inroads of the Bacillus coli communis 
and of saprogenic saprophytes, from adhesion to the intestines. Con- 
sidering our theories of invasion, it must be held to be a remarkable 
thing that the occurrence of abscess in a cystic ovarian tumour is so 
rare, yet, follicular abscess the result of bacterial infection is much 
more common. This fact may be due to the open wound produced by 
the rupture of a follicle giving an easy entrance into the ovarian tissue 
to the pathogenic organism, thus forming a point of departure for 
further inroads. 

The modes of entrance of bacteria to the ovary are, in general, iden- 
tical with those already discussed under the head of infections of the 
Fallopian tube. These channels are: First, the lymphatics and blood 
vessels which establish a direct line of transmission from the external 
genitalia, and the mucosa of the vagina and uterus, to the ovary. (See 
Tuberculosis of the Fallopian Tubes.) This is specified as the channel 
of preference for all bacteria except the gonococcus. Secondly: The 
female genital tube connects the surface of the ovary with the external 
air, and any infection may traverse this distance from the surface of 
the body (practically from the vagina) to the surface of the ovary, to 



INFECTIONS AND INFLAMMATIONS OF THE OVARIES 



571 



cause an inflammation. This is specified as the channel of preference 
for the gonococcus. Thirdly: It has been clearly demonstrated that 
bacteria may pass through the wall of the intestine (especially at a 
point of ulceration), gravitate to the pelvis, and cause infection of the 
ovary (Grawitz, Stoecklin), or that bacteria may pass from the intestines 
through adhesions which bind them to it. This will be specified as the 
channel through which the Bacillus coli communis usually passes. 

A study of the specific characteristics of each type of infection, 
and their relation to each other, will be best carried out by considering 
separately the most important of the bacteria that may cause ovarian 
disease. Yet, this treatment of the subject is only possible after a 
very positive statement already made (see Fallopian Tubes) to the effect 
that every infection in the genital tract is a mixed infection. 

Individual Infections of the Ovaries. — Streptococcous infection of 
the ovaries is of frequent occurrence. These bacteria reach the ovaries 
through the avenues of the lymphatics and blood vessels, by which 
they are distributed directly to the parenchyma and inaugurate their 
activities by the development of small miliary abscesses. A section 
of ovarian stroma will show a small abscess cavity the pus of which 
abounds in streptococci, and the surrounding stroma will be studded 
with migrated leucocytes (Fig. 241). Sooner or later, small segments of 
ovarian tissue become de- 
tached and are found in 
the pus of the gradually 
enlarging abscess cavity. 
Such detached segments 
of tissue will show it to 
be studded with strepto- 
cocci (Fig. 212). These 
abscesses may develop at 
any point from the cen- 
tre to the circumference 
of the ovary, even in its 
wall. They form irregu- 
lar cavities, and are con- 
sequently liable to be 
mistaken for purulent 
cysts. In many cases, 
however, there is no dif- 
ficulty in establishing 




Fig. 241. 



A small abscess cavity, the pus of which 
abounds in streptococci. 1 ' — Keed. 

their real character. Sev- 
eral foci of suppuration may be simultaneously established, resulting 
in the coalescence of their cavities and the consequent development 
of one relatively large abscess. An ovary that is the seat of this form 
of infection is very liable to become adherent to its neighbouring 
Fallopian tube. A remnant of necrotic partition may be observed in 
some cases between coalescing pus cavities (Fig. 243). The suppurat- 



572 



A TEXT-BOOK OF GYNECOLOGY 







-% 






W^w^m^'m 




4m ^. y 



tm% 



ing cavity in the ovary, however, is generally separated from the 
purulent accumulation within the tube by a barrier of formed tissue, 
which may itself be the field of more or less diffuse infection by the 

streptococcus, and melt down to 
form a wide communication be- 
tween the tubal and ovarian ab- 
scess cavity. A streptococcous 
infection of the ovary may, how- 
ever, result in abscess of that 
organ to its complete destruction, 
without the formation of pus in 
the tubes, and with the tissue 
between the two entirely intact 
(Fig. 244). 

In studying the pathology of 
infection of the ovaries by the 
streptococcus, it is important to 
bear in mind the antecedent 
chain of morbid events. The in- 
fection having occurred primarily 
through some traumatism or 
abrasion in the uterus, generally 
in connection with parturition or 
the puerperium, the micro-organ- 
isms may manifest their activity in the uterine muscular is; or they may 
find their way through the lymphatics into the surrounding cellular tis- 
sue; or they may continue their journey and invade the adnexa. The 
invasion may be arrested at any one of these three stages, or a given case 



353*! * ***f '* 









**&&* 






£&£ 



£i%. 



Fig. 242. — -" Detached segments of tissue will 
show it to be studded with streptococci." 
— Reed (page 571). 



m 

SIP 



^7W 






'-■X-' .••'■ ' '•* 



5"> 



mm 



&i •::'>' >V^ Is & v «£&li<W^&«^A 









^* 



Fig. 243. — " A remnant of necrotic tissue may he observed in some cases between coalesci 
pus cavities." — Reed (page 571). 



ng 



INFECTIONS AND INFLAMMATIONS OF THE OVARIES 573 



may exemplify all three of the stages, and this, occasionally, with such 
rapidity, that they may appear to be coincident. The virulence of the 
micro-organisms and the susceptibility of the patient are the two factors 
which determine the clinical conduct of the infection at the various 
of its 




is 01 its invasion. 
Thus, an infection of the 
uterine wall may be ar- 
rested, either spontane- 
ously or by treatment, 
and resolution may fol- 
low; or active suppura- 
tion may develop. A 
similar infection of the 
circumuterine tissues 
may have a similarly 
variable course and the 
same may be true of the 
appendages. The inter- 
val between either of 
these progressive stages 
of invasion may be of 
variable length. It thus 
happens that the strepto- 
coccous infection of the 
uterine appendages may 
develop remotely in 
point of time from the 
original infection; or it 
may be practically a si- 
multaneous occurrence. In any event, the history of the case and 
the revelations of histological examination will alike show that the in- 
vasion has taken place through one or the other, or both, of the circula- 
tory media. 

It is entirely apparent that the ovarian lesion is only a part of the 
clinical picture presented by such a streptococcous infection. The 
lesions in the uterus and the Fallopian tubes have been previously 
described; yet it seems desirable to call attention at this point to 
the severe " perioophoritis " that occurs in these cases. A variable 
degree of peritonitis is always set up which results in the destruction 
of the peritoneum, in large deposits of fibrin, and in adhesions that bind 
down the ovary to surrounding organs, until it is so completely covered 
in, that its liberation becomes one of the most difficult operations of 
the surgeon, and can only be accomplished by actual dissection, which 
leaves a raw cavit}^. In fact, the symptoms from which the patient 
suffers after the subsidence of a pelvic peritonitis, are explained almost 
wholly by this perioophoritis with the accompanying adhesions. In- 
deed, this part of the ovarian lesion has led to a distinct classification 



Fig. 244. — " A streptococcous infection of the ovary may- 
result in abscess of that organ to its complete de- 
struction. 1 ' — Eeed (page 572). 



574 A TEXT-BOOK OF GYNECOLOGY 

by some authors as " adherent and bound-down ovaries/' and this diag- 
nosis will be found in many case books as the indication for operation. 

Gonococcous infection of the ovaries is of relatively the most 
frequent occurrence. The inflammation in these cases manifests itself 
primarily upon the surface of the organ. This is accounted for by the 
fact that, in at least a vast majority of cases if not in all, infec- 
tion of the upper genitalia by the gonococcus occurs by the progressive 
invasion of contiguous mucous surfaces. In this way, the infection 
travels from the vagina through the endometrium, through the tubal 
mucosa, until it reaches the surface of the ovary. Here, it becomes the 
exciting cause of an inflammation which is manifested more distinctly 
in the enveloping tunic (perioophoritis), than in the deep stroma (par- 
enchymatous oophoritis). Yet, a moment's reflection upon the anat- 
omy will show that the division of the inflammation of that organ 
into superficial and interstitial can not be justified, as neither the 
cellular nor the circulatory arrangement of the ovary will permit a 
definite limitation of the inflammation to either one or the other 
structure. It is a fact of ordinary observation, however, stoutly 
affirmed by Eeymond, that the gonococcus attacks the surface of the 
ovary and is never demonstrable in the pus of an ovarian abscess; nor 
has he ever seen the cyst of an ovary become purulent in the presence,, 
or in consequence, of gonorrheal salpingitis. He has, however, ob- 
served as the result of gonorrheal contamination of the surface of the 
ovary, peripheral sclerosis and the formation of numerous follicular 
cysts beneath the sclerotic envelope. It is precisely the development 
of this sclerosis in the peripheral layer of the ovary that prevents the 
rupture, and causes the subsequent degeneration, of the gradually 
maturing Graafian follicles. (See Small Cysts of the Ovary.) 

It must be further stated, however, that even though the above 
represents the usual conditions, a transmission of the gonococcus by 
contiguity and passage through the tissues, and its transfer by the 
blood and lymphatic vessels, are not only possibilities, but are held 
by Luther and Wertheim to be frequent. A mixed infection in gonor- 
rhoea is, perhaps, the rule, and any reasoning concerning the course of 
the transfer must be qualified by this possibility. 

The inflammatory reaction of the neighbouring peritoneum, and 
the production of adhesions in a gonorrhoeal inflammation of the 
ovaries, will be very similar in their nature to the processes caused by 
the streptococcous infection, and will vary with both the intensity of 
primary infection and the duration of its action. 

Pneumococcous infection of the ovaries, although rare, is on rec- 
ord. Von Rosthorn, Zweifel, Frommel, and Witte, have each reported 
cases in which this micro-organism was demonstrated in the pus of 
an ovarian abscess. In each instance, it occurred independently of 
either pneumonia or pulmonary tuberculosis. Microscopical sections 
showed the abscess wall to contain numerous pneumococci, mingled 
with broken-down tube wall and ovarian tissue. Both inoculation and 



INFECTIONS AND INFLAMMATIONS OF THE OVARIES 575 

tube cultures yielded the pure micro-organism. It would seem that, 
in its manner of invasion, and in its effects upon the ovarian tissues, 
the pneumococcus differs from the streptococcus (see Pneumococcous 
Infection of the Fallopian Tubes) in these points, viz.: First, it may 
enter by way of the general circulation; secondly, there is a remark- 
ably severe invasion of the peritoneum as shown by the severe adhe- 
sions; thirdly, the macroscopical appearance of the pus, which is thick 
and very tenacious, and resembles that seen in empyema following 
pneumonia caused by the Micrococcus lanceolatus; and fourthly, the 
fatal cases of Frommel and Witte speak of a very high degree of viru- 
lence. 

Martin suggests the possibility of a diagnosis in the absence of a 
history of labour at term or interrupted, a gonorrheal infection, and 
in the presence of an evident severe perimetritis. 

The Bacillus coli communis is a well-established cause of ovarian 
abscess in a small percentage of cases. It is a significant fact in con- 
nection with the mode of infection, that a colon-bacillus infection 
never occurs except in an ovary which has previously been adherent 
to the bowel. It would be rash to declare that the other channels may 
not serve as the means of transfer for this germ, but such has not 
been observed. The bacteria are found entirely in the pus and on 
the surface of the abscess wall. The main characteristic of such a 
bacterial invasion is the supervention of acute constitutional and local 
symptoms upon a previous pelvic inflammation. 

The unusual bacteria found in ovarian abscesses are actinomyces, 
described by Zemann; the bacillus of malignant oedema by Witte and 
others; the Bacillus proteus Zerikeri by Robb; and inoffensive sapro- 
phytic bacteria by many observers. 

Tuberculosis of the Ovary. — Many of the older writers, including 
Virchow and Rokitansky, have stated that tuberculous oophoritis is of 
such rare occurrence, even if it ever occurs, that its consideration is 
useless. At the present day, however, we know that it is a relatively 
frequent disease of the ovaries, that it may be either primary or second- 
ary, and that it deserves practical attention on the part of the gyne- 
cologist. As before mentioned, the order of frequency with which 
tuberculous disease of the female genital organs occurs in various loca- 
tions is, tubes, uterus, ovaries, vagina, cervix, and vulva. Schottlander 
has collected 153 cases of reported tuberculous oophoritis, but accepts 
only 30 of these, in which a microscopic examination was reported. He 
admits that many of those in which the microscopic examination was 
not made, were undoubtedly tuberculous, yet thinks they can not have 
a scientific value. It is only since the advent of the means for exact 
research, and the cultivation of routine methods of examining all 
material obtained from the autopsy table or the operating room, that 
the frequency of this condition has been demonstrated. Such methods 
have made it clear that ovaries showing no macroscopical change may 
yet contain numerous miliary tubercles (Wolff, Schottlander, Franque). 



576 A TEXT-BOOK OF GYNECOLOGY 

The mode of infection by the tubercle bacillus is variously ex- 
plained by authors. Klebs believes that the tube is the usual source of 
infection, and that the infection is transmitted in continuity of tissue, 
rather than by means of the blood. Others believe that the blood is 
the most probable carrier of the tubercle bacilli (Mosler, Guillemain). 
yet Jani and Westermeyer-Jacksch have failed to find the tubercle bacil- 
lus in the apparently healthy ovaries of a series of phthisical patients, 
and the latter investigators obtained a positive result in only one case, 
by the inoculation of the peritoneum of animals by such ovaries. 
Schottlander believes that the peritoneum is the usual source of infec- 
tion, yet accepts a tubal origin, and believes that the bacteria may often 
enter by an abrasion in the vagina or vulva, and ascend to the ovary 
by way of the lymphatics without a lesion at the point of inoculation. 
Franque has directly traced such an infection from an abrasion in the 
vault of the vagina. A primary localization of the tubercle bacillus in 
the ovary is extremely rare. Jacobs has reported such a case of one- 
sided tuberculosis of the ovary, where the Fallopian tube showed only 
an interstitial inflammation and the lungs were certainly only in- 
volved after the operation. Cases in which the process is primary in 
the genital tract are not so rare (Franque, Schottlander, and others). 

Morbid Anatomy. — The anatomical changes characteristic of ovarian 
tuberculosis are the formation, in the majority of cases, of smaller or 
larger caseous foci, while the merely miliary form is seldom met with. 
Along with these changes, there is usually present in the organ an 
inflammatory condition of a more specific character, which results par- 
ticularly in an atrophying process in the follicle. The caseous masses 
vary in size from that of a millet seed to that of a marble, may run to- 
gether to form apple-sized cavities in which almost all ovarian tissue is 
destroyed, or, as has occurred in certain reported cases, the ovarian na- 
ture of the huge abscess cavity may be difficult of demonstration. Be- 
sides these changes, there exists a simultaneous adhesive tuberculous 
pelviperitonitis of varying degree. Heiberg has often found a forma- 
tion of small caseous foci in the dilated follicle, closely resembling a 
degenerated rupture follicle, yet the process seems to localize by prefer- 
ence in the stroma. This fact has been demonstrated as the rule in 
the collected cases, and has been further demonstrated by the experi- 
ments of Acconci, in which the injection of a pure culture of tubercle 
bacilli into .the ovary always resulted in an interstitial deposit of 
tubercles, but never so when into the follicle. Schottlander has ob- 
served follicle tuberculosis, however, in rabbits. 

It is a well-established fact that a miliary tuberculosis may exist 
in the apparently healthy ovary of tuberculous women (Schottlander). 
H. J. Whitacre has observed a perfect Graafian follicle in the midst of 
ovarian stroma which was in a state of complete tuberculous infiltra- 
tion (Fig. 245). The miliary tubercles are usually found in the super- 
ficial zone of the ovarian tissue, but sometimes find their way deeper, 
and always possess the usual characteristics of epithelioid, giant, and 



INFECTIONS AND INFLAMMATIONS OF THE OVARIES 577 




Fig. 245. — " A perfect Graafian follicle in the midst 
of ovarian stroma which was in a state of complete 
tuberculous infiltration." — Whitacre (page 576). 



round-celled tubercles, but the tubercle bacilli are seldom found. 
Whitacre and Wolff have noted the appearance of considerable num- 
bers of very large giant cells, completely alone and apart from other 
tuberculous products, in 
the stroma of the organ 
(Fig. 2-i6). Schottlander 
has called attention to the 
fact that the normal fol- 
licle, especially when cut 
just to one side of the 
ovum, will give rise to a 
collection of cells that very 
much resemble a miliary 
tubercle. The same confu- 
sion may also arise from an 
atrophied follicle. Frerichs 
has further stated that 
caseous foci in the ovary are 
not necessarily of tuber- 
culous origin. It becomes 

apparent that this confusing feature in the usual histological picture 
(Fig. 247) of tuberculosis, when associated with the extreme difficulty 
encountered in demonstrating the tubercle bacillus, will render even 

a microscopic diag- 
nosis difficult. 

The symptoms of 
the disease vary with 
the extent of the 
involvement both of 
the ovary and of 
the peritoneum. The 
miliary form of the 
disease will give no 
symptoms, while the 
more advanced case- 
ous forms may give 
rise to the most se- 
vere symptoms of 
pelvic abscess. 

The diagnosis of 
the condition pos- 
sesses a scientific 
rather than a practi- 
cal interest, since it is 
impossible to recog- 
nise the earlier forms by any known means, and the later forms are 
either associated with disease of other organs, or are operated on under a 
38 




Fig. 246. — " Whitacre and Wolff have noted the appearance 
of very large giant cells.'" — Whitacre. 



578 



A TEXT-BOOK OF GYNECOLOGY 



mistaken diagnosis. Martin states that we may diagnosticate a tubercu- 
losis of the ovary when the tube end is not enlarged but the ovary is 
represented by a tumour the size of a goose's egg, which is glued to the 
side of the uterus and only slightly sensitive. Hegar considers the glu- 
ing of the tumour to the 
uterine ligament, as in 
parametritis, a character- 
istic feature. That mis- 
takes can be made, even 
in the microscopic exami- 
nation, is certain (Mad- 
lener), yet the appear- 
ance of perfectly typical 
miliary tubercles in some 
part of the structure is the 
rule, and the regular ar- 
rangement of the epithe- 
lial cells of a follicle with 
cement substance be- 
tween them, will usually 
serve to give a correct di- 
agnosis. Again, the pres- 
ence of giant cells does 
not remove every diffi- 
culty of diagnosis, since 
an egg follicle with a 
moderately thick epithe- 
lial layer, and filled by granular material, my resemble greatly the giant 
cells of tuberculosis. Yet, in giant cells, the nuclei are less regularly 
arranged than in a follicle, and the long axis of the nucleus is tangential 
in the follicle and radial in the giant cell. It becomes apparent that a 
thorough microscopic examination is an unavoidable necessity. 

Treatment. — The treatment of ovarian tuberculosis will be almost 
exactly that of the tubal type, and will depend upon much the same 
reasoning with reference to the general condition of the patient. One 
of the unexplained results of abdominal surgery is the almost constant 
recovery of cases of tuberculous peritonitis, following even exploratory 
incision of the abdominal cavity. These cases, even when associated 
with extreme ascites, appear to undergo resolution, following the open- 
ing and irrigation of the peritoneal cavity. Eeed has cases alive and 
well seven years after operation, the peritoneum at the time of opera- 
tion being thoroughly studded with tuberculous deposits. 




Fig. 247. — " The usual histological picture of tuberculo- 
sis." a, Graafian follicles ; &, circumscribed collection 
of epithelioid cells containing bodies that appear to 
be giant cells ; yet this is not a miliary tubercle, but 
a Graafian follicle. — Whitacre (page -577). 



CHAPTER XXXVIII 

TREATMENT OF INFECTIONS OF THE OVARIES 

Preliminary considerations — Natural terminations — Palliative treatment — Con- 
servative treatment — Radical treatment: Oophorectomy, indications; unilat- 
eral — Effects: Primary, secondary. 

The treatment of infections of the ovaries can not be discussed in- 
telligently without taking into consideration the coincidence of similar 
infections of the Fallopian tubes and, frequently, of the pelvic lym- 
phatics. The former of these complications has already been dis- 
cussed (see Infections of the Fallopian Tubes), while the latter will 
be presented in a subsequent chapter. (See Infections of the Pelvic 
Lymphatics.) The ovary, however, presents special points for con- 
sideration when it is looked upon as the organ of ovulation, and when 
its unique morphology is taken into account. Its removal or complete 
organic destruction, when occurring on both sides, implies irremediable 
sterility, the exceptional cases of fecundity following oophorectomy 
not being worthy of consideration as exceptions. The preservation 
of the ovaries or of their function, in all cases in which reproduction 
is desirable, is, therefore, a matter for primary consideration after the 
preservation of the patient's life has been assured. It goes without 
saying, that treatment should have for its object the preservation of 
these organs, when this can be accomplished with safety to the patient's 
health or life. When surgical intervention should take place, as also 
its extent, must be determined by a knowledge of the natural history 
of the morbid changes induced by infections. 

The natural termination of infections of the ovaries depends largely 
upon the character and virulence of the preponderating micro-orgauism 
in the individual case. Streptococcous and pneumococcous infections 
are more dangerous to life than those depending upon the gonococcus. 
The primary danger to life from these infections has, probably, been 
exaggerated. This fact was emphasized by Chrobak (La Semaine 
medicate), who stated in 1893 that the statistics of the Anatomico- 
Pathological Institute of the General Hospital of Vienna showed that 
there had been but 14 deaths from inflammatory diseases of the uterine 
adnexa in about 42,000 cases of that affection, although Schauta 
thought that they were of more frequent occurrence, since he, himself, 
had seen 4 deaths from pyosalpinx in a single year. It is highly prob- 

579 



580 A TEXT-BOOK OF GYNECOLOGY 

able that these infections, taken as they come, if left to themselves 
would yield a much higher mortality than that indicated by either of 
these observers; but even granting this to be true, it does not follow 
that infection of the appendages is the uniform menace to life that 
is ordinarily supposed. It is unfortunate that facts are not at hand 
upon which a more accurate conclusion could be based, for, upon the 
determination of this point rests the justification or condemnation of 
radical intervention — particularly in the presence of acute inflamma- 
tions; but both Chrobak and Schauta agree that, although life is rarely 
compromised by these diseases, they nevertheless expose the patient 
to the most serious complications. These complications vary somewhat 
in character according to the predominating element of infection. 
Thus, gonococcous infection presents a different picture from that de- 
pending upon the streptococcus. 

The gonococcus, which, according to Eeymond, is not found in 
the pus of an ovarian abscess, and which, according to all observers, 
is of less virulence and is shorter-lived in the peritoneal cavity than 
elsewhere, produces inflammation that is manifested with relatively 
greater virulence on the surface than in the parenchyma of the ovary. 
The result of such an infection is to produce an inflammatory exudate 
on the surface of the ovary and on the proximal peritoneal surfaces, 
resulting, in the majority of cases, in adhesions between the two. It 
also produces, first, thickening, and, subsequently, sclerosis of the in- 
vesting tunic. As a result of these changes there occurs follicular 
degeneration. (See Morbid Histology of Ovaritis.) The clinical results 
of these changes are very distressing and very permanent. An ovary 
that is studded with unruptured and degenerated follicles, the pressure 
of which has resulted in the atrophy and practical disappearance of 
the stroma of the organ, is functionally useless. An ovary which is 
the seat of these changes frequently presents to the sense of touch a 
tension greater than that which exists in the eye. It can readily be 
understood that terminal nerve filaments in the ovary are subjected, 
under such circumstances, to an agonizing pressure. As a matter of 
fact, this condition is the most painful with which a woman can be 
afflicted. The exacerbations of pain incident to the premenstrual afflux 
of blood and to the futile efforts at ovulation, are agonizing in the ex- 
treme. Patients thus afflicted manifest every phase of the so-called 
reflex neuroses, and, not infrequently, are the victims of equally dis- 
tressing psychoses. Hysteria, hystero-epilepsy, and their congeners, 
are sequelae of frequent occurrence; while constipation, indigestion, 
self -intoxication and the anaemias, are frequent elements of the clinical 
picture. While this is true, it must be recognised that there are cases, 
relatively few, perhaps, in which there appears to be complete recovery 
of the organ. In streptococcous infection, however, the invasion takes 
place directly into the ovarian stroma, resulting in multiple coalescing 
abscesses and the consequent destruction of more or less of the ovary. 
As elsewhere pointed out, these purulent accumulations may become 



TREATMENT OF INFECTIONS OF THE OVARIES 581 

very large and may find a spontaneous outlet through the intestines, 
the bladder, or the pelvic wall, or directly into the peritoneal cavity. 
Symptomatic recovery may follow any one of the three former, but 
death is the usual result of the last-named complication. Suppura- 
tion of the ovary involving a considerable destruction of the stroma, 
may be drained, either spontaneously, or by operative intervention, 
leaving a certain amount of ovarian tissue which, being yet studded 
with primordial cells, may subserve the function of ovulation. But, 
unfortunately, in at least the majority of these cases, suppuration of 
the stroma is associated with so much inflammation of a peripheral 
character that adhesions result, causing essentially the same painful 
and intractable conditions as have already been described as the 
results of gonococcous infection. When this occurs, there become 
established the essential underlying causes of chronic invalidism. It 
follows, therefore, that, viewed in the light of their natural termina- 
tions, even when these are the most favourable, infections of the uterus 
demand surgical intervention, generally of the most radical kind. It 
is to be hoped that the further revelations of experimental surgery 
may develop some means by which these organs may be either con- 
served, or replaced by structures with functional possibilities. 

Palliative treatment of infections of the ovary must be considered 
with reference to (a) acute, and (b) chronic cases. In acute inflamma- 
tions of these organs, particularly when the history of the case or bac- 
teriological examination of it points to infection by the gonococcus, treat- 
ment should be based upon full recognition of the fact that these 
micro-organisms in the peritoneal cavity are of diminished virulence 
and of short life. The inflammation which they establish may be 
slight or severe, according to the susceptibilities and conduct of the 
patient. That there are some cases that react with greater intensity 
than others to inflammatory influences can not be denied; while exercise, 
particularly if violent, is calculated to augment an inflammatory pro- 
cess that has become established. The indications in these cases are 
for rest and elimination. The patient should be put to bed and should 
be given a saline cathartic. Opium should be avoided, and anodynes, 
if indicated, should consist of other agents of recognised value which 
do not arrest peristalsis. The hot vaginal douche, with glycerine tam- 
pons in the interval, should be employed systematically during the 
first four or five days. In mild cases the symptoms will disappear 
promptly after free catharsis induced by the salines; but patients 
should be kept in bed for several days after the subsidence of the pain. 
Ice-packs over the groin are generally of more value than applications 
of the opposite extreme of temperature, and should be applied from 
the start. In streptococcous infection the symptoms are generally more 
active, constitutional intoxication being more profound. If, in a given 
case, the symptoms do not indicate extreme virulence, the palliative 
measures already indicated may be relied upon; but where there exists 
manifest infection of the uterus, together with implication of the 



582 A TEXT-BOOK OF GYNECOLOGY 

pelvic lymphatics, palliative measures beyond those elsewhere discussed 
(see Streptococcosis Infection of the Uterus) should not be relied upon. 
So soon as the enlargement of an ovary, with associated symptoms, 
indicates the presence of pus in that organ, surgical intervention is 
indicated. 

Pneumococcous infection comes under the same rule. It should be 
stated here that surgical treatment should not be withheld while await- 
ing a precise diagnosis of the character of the infection, but should be 
adopted at once in the demonstrated presence of pus. 

In chronic cases, the treatment is not addressed so much to the 
infection as to its consequences. As a matter of fact, in gonococcous 
infections, which comprise the majority of these cases, the micro-organ- 
isms are eliminated as active factors in the case during the acute stage. 
Under these circumstances, and in the absence of renewed infection, 
that which is generally recognised as recurrent inflammation is hyper- 
emia, induced mechanically by the action of adhesions or by the pre- 
menstrual wave, by the progressive accumulation of unruptured fol- 
licles, by engorgement of the portal circulation due to constipation, or 
by the traumatisms arising either from accident, or from sexual inter- 
course. Eest, laxatives, douches, and tampons, will generally relieve the 
distressing symptoms, the recurrence of which may, however, be 
counted upon in the renewed presence of the same exciting causes. 

The conservative treatment of infections of the ovaries has for its 
object the perpetuation, so far as possible, of the functions of these 
organs. Whether in the presence of acute or chronic inflammation, 
treatment should be addressed to preservation of the organs, whenever 
this can be done consistently with the health and life of the patient. 
It would seem, as an abstract proposition, that an ovary the seat of 
parenchymatous suppuration, should no more be extirpated than a 
finger, the seat of a felon, should be amputated. Unfortunately for 
this hypothesis, however, the morphology of the ovary is such that 
an inflammation, once established in its parenchyma, generally results 
in its functional, if not its organic destruction. (See Morbid Histology 
of Ovaritis.) Cases have been reported in which an ovary, the seat 
of suppuration, has been brought down through a vaginal incision, 
punctured, the pus cavity packed with gauze, and the organ returned 
to the pelvis, with the result of complete recovery. The fact that 
an organ thus inflamed must remain inflamed for a time after opera- 
tion, and that, during such persistence of inflammation, it is liable 
to develop adhesions, must stand as a barrier to the success of this 
treatment in any considerable number of cases. While the infection 
may be relieved, the consequences of the inflammation can hardly be 
averted. In chronic cases, in which the surgeon has to deal, not with 
the infection, but with its consequences, there seems to be a better 
prospect of restoring the organ. Eeed has repeatedly excised a cyst 
or cysts of the ovary, stitched up the incision, and dropped the ovary 
back (Fig. 248). The results of these operations have not always been 



TREATMENT OF INFECTIONS OF THE OVARIES 



583 



satisfactory, and no guarantee can be given to the patient that she 
will be freed from pain. On the contrary, in a series of six such cases 
operated upon by Eeed, all the patients applied for the radical removal 
of the organ before the expiration of three months. Schroder, accord- 
ing to A. Martin, was the first to attempt to remove only the diseased 
portion of an ovary, 
leaving the appar- 
ently healthy part. 
Martin adopted this 
method of practice 
in cases of adherent 
appendages in which 
the patency of the 
tube could be dem- 
onstrated, and con- 
cluded (Volkmann's 
Sammlung hlin ischer 
Vortrage) that the 
remo\ r al of the dis- 
eased portions of the 
ovary did not affect 
recovery from the 
operation; that exci- 
sion of the closed or 
otherwise diseased 
portion of the tube 
did not affect the 
healing process; that 
women who had suf- 
fered such partial 
removal of the ad- 
nexa, were no more 
liable to an exten- 
sion of the disease to 
the healthy portion 
of the resected or- 
gans than women 
whose ovaries were 
normal; and, finally, 
that in all these 

cases of excision, menstruation persisted and conception was possible. 
Several cases of pregnancy have been reported following the adoption 
of these conservative measures. If such measures are contemplated in 
a given case, they should only be practised with the knowledge and by 
the consent of the patient, who should be informed frankly of the lia- 
bility of failure, and of the probable necessity of subjecting herself to a 
second and radical operation before she can be restored to health. 




Fig. 248. — "Eeed has repeatedly excised a cyst or cysts of 
the ovary, stitched up the incision, and dropped the ovary 
back." — Eeed (page 582). 



584 A TEXT-BOOK OF GYNECOLOGY 

The radical treatment of infections of the ovaries consists in the 
removal of the diseased organs. As the Fallopian tnbes without the 
ovaries are useless structures, and as they are generally diseased and 
can be removed under these circumstances without embarrassing the 
recovery of the patient, they too are generally removed. 

Oophorectomy is the name given to the operation for removal of 
the unenlarged ovaries; it is also known as Battey's operation, and 
as normal ovariotomy. It was first performed by Dr. Robert Battey, 
of Borne, Ga., on the 17th of August, 1872, for the purpose of caus- 
ing the artificial and premature occurrence of the menopause in an 
otherwise incurable patient. The operation succeeded and the patient 
was restored to health. Battey, during the remainder of his life, op- 
erated frequently on this indication and with remarkable success. His 
purpose was to arrest the menstrual molimen, and to abolish thereby 
a painful and nervous class of symptoms which all other treatment in 
his hands had failed to cure. With this premature and forced change 
of life, came also a suspension, and finally an abolition, of the class 
of troublesome symptoms which culminated at the monthly period. 
In neurotic patients they frequently explode in violent hysterical 
attacks, while in aggravated cases insanity has sometimes resulted. 

During the same year, February 11, 1872, Lawson Tait, in Eng- 
land, removed the ovaries and tubes for the cure of chronic inflamma- 
tions and pus collections in the uterine appendages, and Hegar, in 
Germany (July 27, 1872), removed the ovaries to arrest the growth of 
small fibroid tumours of the uterus, and the hemorrhages caused by 
their presence. Tait's operation, upon what are now known as " pus 
tubes," is referred to in another part of this work. (See Infections of 
the Fallopian Tubes.) 

Several of the conditions for which Battey operated are now relieved 
by less formidable treatment. The wave of sacrificial pelvic surgery 
seems to be passing, and a conservative tide, having for its object 
the saving of one ovary and part of the other if possible, is rising. 
(See Unilateral Eemoval of Ovaries.) The sudden and stormy onset 
of the change of life is thus prevented, and, while the diseased tissues 
have been resected, enucleated, or otherwise removed, the woman does 
not feel unsexed, as she calls it, and " so totally different from other 
women." 

The operation was, for a time, overdone. Too many ovaries were re- 
moved by youthful inexperienced operators. The pendulum began 
gradually to swing the other way, till now, surgeons hesitate somewhat 
to perform oophorectomy, even in the few cases where their best judg- 
ment dictates it to be the operation best suited to cure their patients. 

The indications for oophorectomy, as now practised, are chiefly in- 
fections of the ovaries; inflammations and their consequences; certain 
rare and otherwise incurable cases of dysmenorrhea; certain otherwise 
incurable cases of ovarian pain, independent of the periods, and mak- 
ing the patient an incurable invalid; clear cases of menstrual epilepsy; 



TREATMENT OF INFECTIONS OF THE OVARIES 585 

menstrual insanity, when the attacks occur only during the menstrual 
week, the patient being free from them during the interval; osteo- 
malacia; and bleeding uterine fibromata, of small size, where the 
patient declines hysterectomy and other means fail. Eecently, oopho- 
rectomy has been proposed as a cure for mammary cancer, but authentic 
reports of favourable results are lacking upon which to found an in- 
dication. 

The technique of the operation and the preparation of the patient, 
the surgeon, the nurses, and the operating room, do not differ materially 
from that of any median abdominal section until the abdomen is 
opened. (See Abdominal Section.) As there is no tumour, the in- 
cision need not be more than &| or 3 inches long. Two fingers, pref- 
erably of the left hand, are passed down to the top of the uterus and 
out along the tube and ovarian ligament to the ovary. Any adhesions 
are gently separated and the ovary, being grasped between the two 
fingers, is drawn up to and out of the abdominal opening. The tube 
should 'be well drawn up, also, and the pedicle transfixed as near the 
uterine cornu as possible, embracing the tube in its sweep. The loop 
of the ligature should be drawn through at least 6 inches and cut, 
thus making two ligatures, one being tied on one side, and one on the 
other, of the included tissues. Should any doubt exist as to the 
security of the constriction, one thread may be carried round the whole 
mass in the groove formed by previous ligatures, and the stump thereby 
doubly secured against any subsequent bleeding. A sufficient button 
of tissue should always be left where the ovary and tube are cut away, 
to prevent the ligature from slipping off during the vomiting and 
restlessness of the patient while recovering from the effects of the 
anaesthetic. The other ovary and tube are found in the same way 
as the first, brought to the surface, ligated, and cut off. 

As in many cases the aim in oophorectomy is to arrest menstruation 
with all that it implies, great care should be exercised in such cases 
to remove every vestige of both ovaries and tubes down to as near the 
uterus as possible. In order to remove the nerve supply which, it is 
asserted by Arthur W. Johnstone, of Cincinnati, and others, presides 
over the menstrual act, some surgeons remove a V-shaped piece of the 
uterine cornu and stitch together the sides of the cavity instead of 
applying the regulation ligatures to a pedicle. 

There is rarely any loss of blood, and the peritoneal cavity not 
having been soiled in any way, no delay is necessary to complete a 
" toilet," and the abdominal incision is closed in the usual way. (See 
Abdominal Section.) The operation is frequently completed by an 
expert gynecological surgeon in fifteen minutes, and certainly should 
not consume more than half an hour by any one. 

The unilateral removal of the ovaries or of the uterine appendages, 
leaving the other and apparently healthy appendages in situ, remains 
one of the moot questions of surgery, and one which presses itself for 
consideration in connection with conservative measures. The removal 



586 A TEXT-BOOK OF GYNECOLOGY 

of any organ not already the seat of disease, is against the instincts 
and impulses of surgery; and, yet, the frequency with which the re- 
maining and apparently healthy ovary has become diseased in patients 
from whom the other and infected ovary has been removed, has raised 
the question as to the expediency of removing both organs at the first 
operation. In approaching a decision of this question, it is to be re- 
membered again that the majority of all these infections are gonor- 
rheal in character; that an infection may travel up the uterus and 
out through the tube on one side, before passing up and out through 
the tube on the other side; and that a remaining ovary is, therefore, 
liable to inflammation caused by the later extension of the infection 
through the Fallopian tube of that side. On this point we may well 
accept the observations of Lawson Tait (American Journal of Obstetrics, 
1887), as follows: "Actuated by the sound principle that no organ 
should be removed which is not diseased, in all the cases of the varie- 
ties of chronic, inflammatory, mischief in the uterine appendages, 
which have come under my care, I have not, in a single instance, 
removed the second set of appendages when they have been ascer- 
tained to be healthy. ... I have been made painfully familiar with the 
frequency with which operations of this kind have proved absolutely 
useless for the purposes of the operation, and where the disease has 
recurred in the other side and demanded a second surgical interference. 
. . . But the opinion which I have formed ... is that if a patient is 
suffering sufficiently to justify an abdominal section for chronic in- 
flammatory disease of the uterine appendages, and only one side is 
found to be affected, the operation, to be of that lasting and complete 
benefit to the patient which we desire all our operations should have, 
must be made bilateral. On such a point as this, of course, the desire 
of the patient must be paramount as upon most others, and if a patient 
placed herself under my care for such an , operation, and made it an 
imperative condition that I should not, under any circumstances, re- 
move the second set of appendages if they were found healthy, I 
should yield to her decision; but I should argue the question with 
her, and advise her not to subject herself to the risks of a second 
operation, as seems to be by far the greater tendency in unilateral 
operations." 

The effects of removing the ovaries must be considered with refer- 
ence to their (a) primary and (b) secondary effects. 

Primary effects take into consideration the mere question of sur- 
gical recovery — the healing of the wound, and the getting up of the 
patient. The question of mortality from the operation has established 
the safety of the procedure. Numerous operators have had long series 
of cases without a death. Tait once reported a series of 139 consecu- 
tive operations, the majority of them involving the removal of the 
ovary, without a death. The mortality from the operation should be 
studied with reference to (a) the character of the infection; (b) the 
constitutional state of the patient at the time of operation; (c) the 



TREATMENT OP INFECTIONS OF THE OVARIES - 587 

environment of the patient; and (d) the technique adopted. It may- 
be stated without hesitancy that cases of streptococcous infection, 
whether operated upon early or late, yield the largest percentage of 
deaths. Eecent acute infections in which the pus is yet virulent, are 
more dangerous subjects for operation than those in which the micro- 
organism has reached its vital limitation. This latter remark, how- 
ever, must not be accepted as a reason for permitting the pus of active 
and virulent infection to become innocuous before operation, for such 
delay without constant observation is fraught with extreme hazard to 
the patient — a hazard greater than that of operation. This leads natu- 
rally to a consideration of the constitutional state of the patient at the 
time of operation. Oophorectomy done in the presence of an acute 
constitutional sepsis is always attended with a high mortality; and yet 
the majority of these cases can be said to have no prospect of recovery 
at all without operation. It is in these cases of acute virulent infec- 
tion with more or less pronounced constitutional intoxication, that the 
conservative measure of tentative puncture and drainage should be 
practised. (See Vaginal Drainage.) The surroundings of the patient 
have much to do with her recovery. Nothing is more clearly demon- 
strated than the great advantage of a well-appointed and properly con- 
ducted hospital in the management of these cases; and it may be said 
with equal force that a poorly conducted and an improperly constructed 
hospital is more dangerous to the patient than any other possible sur- 
rounding. The mortality from abdominal section in cases of this class, 
may be conservatively placed at from 15 to 20 per cent when done 
either in poor hospitals or in no hospitals, and at less than 5 per cent 
when done in well-appointed and well-conducted institutions. The 
question of technique can not be discussed without taking into con- 
sideration the more personal element in the equation presented by the 
operator himself. It goes without saying that these operations, to be 
most highly successful, must be done with the greatest skill, and that 
skill can not be expected except as the result of training and experi- 
ence on the part of the operator. The lives that are constantly sacri- 
ficed by untrained men who simply wish to try their hand at abdominal 
surgery, would fill a scarlet book of horrors. 

The secondary, or remote, results should be considered with refer- 
ence to (a) menstruation; (b) the sexual function, including repro- 
duction; (c) the menopause; (d) the intrapelvic state; and (e) the gen- 
eral constitutional condition. 

Menstruation is arrested in the majority of patients from whom 
both ovaries have been removed. Pfister studied 179 cases operated 
upon by Kuhne, between 1880 and 1896, and collected statistics from 
various other sources. He found, on a basis of 715 cases, that men- 
struation ceased in 87.5 per cent, the percentages of cessation in the 
various lists varying from 75.6 to 97.3 respectively. In a majority of 
cases there occurs a sort of post-operative metrostaxis, which may 
recur a few times after intervals of varying length, but this is not 



588 A TEXT-BOOK OF GYNECOLOGY 

to be looked upon as normal menstruation. A few patients menstruate 
during the first few months following complete extirpation of the 
ovaries and then cease. The reasons for the perpetuation of menstrua- 
tion in the 12.5 per cent of Pfister's cases — and they are alluded to 
only because they may be accepted as an index of cases in general — are 
not given, and in the nature of things are not ascertainable. The 
fact, however, that in many cases of oophorectomy it is necessary to 
leave a small segment of ovarian tissue in situ for the purpose of main- 
taining the ligature in position, and the fact that a similar segment 
is frequently left through carelessness in excising the ligatured ap- 
pendages, will probably explain the majority of continuances of men- 
struation. It is known that in many cases in which more or less ovarian 
tissue is left designedly, the menstrual function persists. Bantock, 
Eeed, and numerous other operators have reported cases of the long 
persistence of menstruation after both ovaries were known to have been 
completely removed. Gonzalez, of Diriamba, Nicaragua, reports (New 
York Medical Journal) an interesting case of persistent menstruation 
following, not only the complete removal of both ovaries, but of the 
uterus also. 

The sexual function as influenced by oophorectomy, should be 
discussed with reference to (a) genital sensation, and (b) reproduction. 
With reference to the genital sensation, including libido sexualis, it 
should be understood at the start, that neither is as uniformly existent 
among women as among men. Eelative to this question Lawson Tait 
observed, that when it is " carefully inquired into, and without preju- 
dice, it is found that women have their sexual appetites far less de- 
veloped than men, a fact explained by the process, necessary in evolu- 
tion, that the male has always been the struggling and aggressive 
creature. When the child-bearing period of a woman's life passes away, 
there goes with it a certain amount of her, sexual appetite. In a few 
cases the appetite entirely disappears, but in an equally large number 
of instances it becomes exaggerated, sometimes grotesquely so. In 
the majority of women the appetite lessens, and even disappears, during 
the time of the climacteric disturbance, and then returns to its former 
condition, when the change has been effected." The sexual appetite 
in its relation to oophorectomy, conforms to this law, and can not, 
therefore, be said to be unhealthfully modified. This theoretical view 
of the case seems to be supported by an investigation of the actual 
facts. Pfister reports upon 99 women, in 19 of whom the desire 
remained normal; in 24 it seemed somewhat diminished; in 35, in 
many of whom it had never been strongly developed, it was extin- 
guished, while in 21 it had never been present. Women have con- 
ceived after the extirpation of both ovaries, and, for that matter, of 
both Fallopian tubes. Cases of this kind have been reported by Sippel 
(British Medical Journal), Sutton (Transactions of the American Gyne- 
cological Society) and Dunn (Annals of Gynecology and Pediatry). These 
cases are distinctly exceptional, and point to the fact that an ovule pre- 



TREATMENT OF INFECTIONS OF THE OVARIES 589 

viously evolved may remain for a considerable time and retain its 
vitality in the folds of either the uterine ostium of the tube, or of the 
endometrium. 

The menopause is generally precipitated with abruptness following 
the removal of the ovaries. The patients complain, from the very start, 
of hot flushes, and there is a constant sensation of temperature vacillat- 
ing between heat and cold. The face burns, even without a correspond- 
ing turgescence of the cutaneous capillaries, although there do occur, to 
a certain extent, repeated changes from florid to pale. Associated with 
these phenomena are the more or less evanescent, but none the less 
distressing, nerve storms incident to the climacterium. (See The Meno- 
pause.) It can not be said that these phenomena differ in quality 
from those of the natural menopause, although they generally occur 
with more precipitation and greater violence. In some patients, how- 
ever, they are but little noticed, and in all cases they disappear in 
from twelve to twenty-four months. It is the distressing character 
of these symptoms, in certain cases, that has prompted surgeons to 
attempt the mitigation of their severity by leaving in position a part 
or all of an ovary, even after the removal of the uterus and Fallopian 
tubes. Satisfactory reports have been offered by Bland Sutton and 
others, and it is probable that the practice will find increasing favour 
with operators. 

The general system is influenced within certain limits by removal 
of the ovaries. In these cases, there occurs to a certain extent an 
exemplification of the law of antagonism between growth and genesis. 
When growth is active, the reproductive function is in abeyance; when, 
in turn, the reproductive function ceases, growth again attains its 
normal limit. This is shown in the increasing rotundity of figure fol- 
lowing the normal menopause. The same tendency exists when the 
change of life is induced, artificially, by oophorectomy. In Pfister's 
table, 52 per cent of the collected cases showed a tendency to increase 
in flesh; in 30 per cent the weight remained the same; while nothing 
is said about the remaining 18 per cent. With regard to those who 
increased in flesh, it is to be remembered that they were reduced by 
disease preceding the operation, and that, in many instances observable 
in the practice of all operators, the increase of flesh amounts to noth- 
ing but the resumption of the normal standard. Pfister by his inves- 
tigations collected accurate data by which to refute many prevailing 
notions about the constitutional effects of oophorectomy — notions 
the fallacy of which have been known to operators for decades. The 
vulgar idea that women who have lost their ovaries become gross and 
masculine, acquire bass voices and raise whiskers, is only an indica- 
tion of popular ignorance which occasionally finds expression by an 
asinine physician. The effect of removal of the ovaries upon general 
metabolism has been a subject of inquiry, which has been given a 
fresh impetus by the investigations of Curatullo and Tarulli (Annali 
di Ostetricia e Gi?iecologia), investigations obviously undertaken for the 



590 A TEXT-BOOK OF GYNECOLOGY 

purpose of establishing the existence of what they designated an in- 
ternal secretion of the ovary. In a series of observations on previously 
castrated lower animals, they observed variations in the elimination of 
metabolic products; while in osteomalacia they assumed to find a 
clinical confirmation of the theory that the ovaries secreted something 
which could not be found, but which, nevertheless, exercised an im- 
portant influence over tissue change. They found, in brief, that 
ablation of the ovaries modified metabolism, increased phosphates in 
the urine, changed the nitrogen curve either up or down, diminished 
the elimination of carbonic acid and the absorption of oxygen, and 
increased the weight. In applying their doctrine to women they failed, 
however, to take into account that every fact which they had noted was 
consistent with a return to the normal equilibrium of nutrition. They 
mentioned that the injection of ovarian juice caused an increased elimi- 
nation of phosphates, proportionate to the amount injected, but they 
failed to take into account the fact, that a similar elimination of phos- 
phates occurred following the similar injection of like foreign ele- 
ments into the circulation. They assumed that this element, whatever 
it was, favoured the oxidation of phosphates, and they called attention 
to the point that, after removal of the ovaries, or before or after 
puberty, there should be an increase of calcareous salts in the bones, 
the deposition of the latter being determined by the action of the 
ovarian juice. It is unfortunate for this theory that, in the natural 
course of events, ovarian quiescence before puberty is associated with 
a minimum, while ovarian quiescence after the menopause is asso- 
ciated with a maximum, of lime salts in the bones. If the position 
of these investigators were tenable, it would follow that the condi- 
tion of the bones before puberty and after the menopause would be 
the same. Relating to this subject, it is interesting to note that Heyse 
(Archiv fur Gynakologie), from a careful microscopic study of ovaries 
removed from osteomalacic subjects, decides that there is no reason 
to infer that there is any diminution in the number of primordial cells 
under these circumstances, and consequently that there is no ground 
upon which to predicate a variation in the so-called " internal secre- 
tion." 

Intrapelvic morbid conditions are always modified, if not always 
cured, by the ablation of the appendages. The restoration of other- 
wise hopeless invalids to symptomatic health, is the crowning triumph 
of this operation in the great majority of cases. Many women after 
passing through this operation, and through the neurotic disturb- 
ances of the artificial menopause, are freed from pelvic pain and are 
otherwise healthy. There are cases, however, and a number of them, 
in which the removal of the ovaries, whether for acute infection, 
chronic inflammation, or cystic degeneration, is not followed by com- 
plete cure, or even pronounced amelioration, of the pre-existing intra- 
pelvic pain. In some of these cases the painful symptoms subside only 
after the lapse of one or two years. The reason for this delay in 



TREATMENT OF INFECTIONS OF THE OVARIES 59 1 

recovery, or failure to recover at all, as the case may be, is to be found 
in the inflammatory changes which have become established outside 
the adnexa. Subserous exudates causing pressure on filaments of the 
sacral plexus, and organized inflammatory products in the parenchyma 
of the uterus causing pressure on terminal nerve twigs in that organ, 
are, for the most part, accountable for this persistence of pain. In- 
flammatory changes of a more or less permanent character in the nerve 
sheaths themselves are to be taken into account in this connection. 
A well-established uterine sclerosis of inflammatory origin is a per- 
petually painful condition. It is for this reason that the French school 
inaugurated the practice of removing the uterus with the adnexa for 
the relief of otherwise incurable infectious inflammations. (See 
Doyen's Operation and Panhysterectomy under Treatment of Infec- 
tions of the Fallopian Tubes.) 



CHAPTER XXXIX 
TROPHIC DISEASES OF THE OVARIES 

Atrophy — Cirrhosis — Hypertrophy. 

Atrophy of the Ovaries. — Atrophy of the ovaries, a physiologic 
change at the climacteric, becomes pathologic when it occurs in women 
during the period of sexual activity. This variety is to be carefully 
distinguished from so-called cirrhosis, the result of disease. More- 
over, it should not be confounded with nondevelopment of the gland 
in women who have never menstruated. 

Causes. — In a well-recognised class of cases, Coe observes that the 
rapid development of obesity in young women is associated with 
scanty menstruation, which may eventually cease entirely. Since the 
uterus is normal in these subjects, there is little doubt that the ova- 
rian function ceases in consequence of follicular atrophy, though 
opportunities for studying this condition anatomically are rare. Coe 
has had a chance to verify his opinion at the operating table in a 
typical case. The intimate relation between the ovarian activity and 
the nutritive processes is illustrated by the fact that, on reducing their 
weight, such patients may again menstruate with a fair degree of 
regularity, the flow again disappearing as they return to their former 
state of obesity. Premature atrophy has resulted from alcoholism, 
syphilis, the acute exanthemata, rheumatism, and typhoid fever, 
though in the febrile diseases there is probably a previous inflamma- 
tory process in the ovary. Prolonged pressure upon an ovary, in con- 
nection with uterine fibroids and broad ligament cysts or disturbance 
of its vascular supply by dense adhesions and exudates, may lead to 
complete glandular atrophy in young subjects. So-called cirrhosis is 
often erroneously described as an inflammatory process. Fibrous de- 
generation would be a more accurate term. While it may represent the 
termination of a previous acute inflammation, it is usually a form of 
chronic hyperplasia in which the follicles are entirely destroyed and 
the ovary is transformed into a mass of firm connective tissue. Such 
ovaries are often associated with chronic salpingitis and pelvic exu- 
dates, leading to the inference that obstruction to the blood supply 
is mainly responsible for this form of atrophy. Atrophic changes may 
follow supravaginal amputation of the uterus when one or both ova- 
ries have been left in situ. 

592 



TEOPHIC DISEASES OF THE OVARIES 593 

Pathology. — An atrophied ovary differs in its microscopic appear- 
ance from the organ after the normal climacteric, not so much in size, 
as in its irregular, nodular shape, and dense, almost cartilaginous, 
consistence. The cortex is much thickened, often from accompanying 
perioophoritis. On section, the surface presents a uniformly firm, 
fibrous structure, with few or no traces of follicles. When these are 
present, they are either atrophied, or, rarely, dropsical, their walls 
being greatly thickened. The arteries are few and their lumina con- 
tracted, and there are no evidences of leukocytic foci. 

Symptoms. — There are no symptoms characteristic of atrophy, if 
we except amenorrhcea and sterility in cases in which both ovaries 
are affected and sexual appetite is in consequence diminished or 
absent. Previously to complete atrophy, menstruation is irregular and 
painful, especially when the glands are buried in adhesions. In fact, 
the symptoms are due rather to the accompanying condition. 

Prognosis. — Great circumspection is necessary in giving a progno- 
sis in these cases, or in promising certain definite results from treat- 
ment. It is idle to expect an anatomical cure or restoration of func- 
tion in an ovary in which the normal stroma and follicles have com- 
pletely disappeared. In the case of the young obese subjects before 
alluded to, in whom the uterus is still of normal size, rigid diet and 
exercise, baths, electricity, and massage (and especially a course at a for- 
eign spa, such as Marienbad) may stimulate the ovaries to renewed 
functional activity. The possibility of conception is doubtful, so that 
it is not right to encourage the patient with false hopes. 

Treatment. — When the atrophied organs are adherent and give 
rise to constant pain and dysmenorrhcea, little is to be expected except 
from operative intervention. In the case of young women who desire 
to preserve their ovaries it may be sufficient to separate adhesions, in 
fact, the writer once saw menstruation return and persist after this 
simple procedure; but when the flow has ceased entirely and the glands 
are transformed into mere fibrous nodules, there is no object in retain- 
ing them. 

Cirrhosis of the ovaries requires at least brief consideration. It 
has been, and is still, the custom to regard the condition of the ovaries 
known as cirrhosis, as a mere sequence of an acute oophoritis. But 
there is ample evidence that this condition may occur independently 
of inflammation. It is found fully developed without antecedent his- 
tory of infection in women under thirty years of age, and it may 
involve one or both ovaries. It gives rise to severe pain in the affected 
ovary, especially before menstruation. Its persistence may lead to 
neurasthenia or to some other form of neurosis. The ovary in these 
cases may or may not be prolapsed, is firm, unyielding, globular in 
form, sensitive to the touch, but usually not adherent. In the earlier 
stages of the disease, the ovary presents a relatively normal appear- 
ance, but as the morbid process progresses, as it usually does, the 
organ contracts at the expense of the vascular stroma or medullary 
39 



594 A TEXT-BOOK OF GYNECOLOGY 

substance until all true gland tissue has been destroyed. As a result 
of the fibrous contractions the surface of the ovary is made to resem- 
ble, in miniature, the convolutions of the brain. It will follow as a 
natural conclusion that the majority of women suffering from cir- 
rhotic ovaries, are sterile. 

The symptoms are not always constant. So true is this, that the 
patient can seldom state definitely when they began. The pain has 
been described as of a sharp, darting, sickening or throbbing char- 
acter, in one or both ovarian regions, but more frequent and severe 
in character in the left ovary. This pain has its greatest intensity 
from a few days to two weeks prior to the menstrual period, and is 
usually accompanied with nervous reflexes, such as hysterical mani- 
festations, backache, etc. In many of the cases, owing to the intimate 
nerve connection with the lumbar ganglia of the spinal nerves, pain 
will be referred to the front and inner side of the thigh and to the 
hip joint. Dyspareunia is absent in many cases, owing to the fact that 
the ovaries are small and are not prolapsed and tender. 

In the early stage of these cases they may be treated, with some 
relief of the pain, by electricity, but the results from this agent have 
not been at all satisfactory. All cirrhotic ovaries do not require re- 
moval. It is in cases where other means have failed, and where the 
woman has been rendered an invalid or her suffering has become almost 
intolerable, that the removal becomes imperative. 

Hypertrophy of the Ovaries. — This may be defined as an enlarge- 
ment of the ovary, the result of former inflammation or chronic con- 
gestion. It is cystic or fibrous, according as the change affects the 
follicles or stroma, though the two conditions are commonly associ- 
ated. 

Causes. — So-called chronic oophoritis leading to hypertrophy, ac- 
cording to Coe, is doubtless the termination of an acute inflammatory 
process, which does not terminate in abscess formation, hence it may 
be due to puerperal or gonorrhceal infection associated with similar 
disease in the tube. But the most common cause is long-standing 
pelvic congestion, such as accompanies tubal disease, peritonitis, and 
uterine and ovarian tumours. A prolapsed ovary, especially when 
surrounded by exudate, is liable to undergo hypertrophy. Chronic 
constipation also is an exciting cause, which fact may account for the 
relatively greater frequency of hypertrophic changes in the left ovary, 
which is not only in close proximity to the sigmoid flexure but has 
a valveless vein. Primary hypertrophy is sometimes traceable to sex- 
ual excess, traumatism, or frequent pregnancy and abortion. Cystic 
degeneration may result from disease of the individual follicles which 
are prevented from reaching the surface of the ovary or, when situ- 
ated in the peripheral zone, can not rupture in consequence of patho- 
logic thickening of their walls or peri-oophoritic adhesions or exudates. 

Pathology. — The follicles become dropsical and few or many cysts 
develop. A hypertrophied ovary may be enlarged to several times 



TROPHIC DISEASES OF THE OVARIES 595 

its normal size, and presents an irregular shape, with one or more 
cysts of variable size, sometimes as large as English walnuts, project- 
ing above its surface; on palpation, there is a more or less distinct 
sense of fluctuation. Or, if the fibrous element predominates, the 
ovary may be globular or oval in shape, with a smooth whitish appear- 
ance and firm consistence. Fibroid ovaries are usually prolapsed, 
from their increased weight, and are often freely movable, though if 
there is accompanying tubal disease they are apt to be buried in exu- 
date. On section, such an ovary shows marked thickening of the 
cortex, with general induration of the stroma due to proliferation of 
the fibrous tissue. A few small cysts with thickened walls are 
seen, or no traces of the follicles remain. The walls of the arteries 
are usually thickened, the lumina are dilated and hyaline degenera- 
tion is common. In cystic hypertrophy the walls of the dropsical fol- 
licles are thickened and they contain a clear fluid, normal, or, not 
infrequently, a single cyst may encroach upon the stroma to such an 
extent that only a narrow zone remains. 

Symptoms and Diagnosis. — The symptoms are often due princi- 
pally to coexisting conditions — adhesions, tubal disease, or neoplasms. 
In uncomplicated cases, the patient complains of severe pain in one 
or both groins or in the sacrum, which is increased a day or two 
before the menstrual flow, sometimes recurring in a paroxysmal form 
during the intermenstrual period. The pain may radiate down the 
thighs and is often accompanied by reflex neuralgia? of the inter- 
costal nerves and pelvic organs. If the ovary is prolapsed in Doug- 
las's pouch, a peculiar sickening pain is felt during defecation and 
coitus. Locomotion is often attended with severe pain in the groins 
and sacrum, extending down the lower limbs; if the ovary is fixed by 
adhesions these symptoms are aggravated. Menstruation is apt to be 
irregular. Menorrhagia is common in connection with cystic hyper- 
trophy. Sterility results from the general disappearance of the nor- 
mal gland tissue, though conception is always possible so long as 
healthy follicles persist. The effect of the local disturbances upon 
the general health may be such that the patient becomes a nervous 
invalid. The various hystero-neuroses are frequently referable to the 
ovarian condition. 

Treatment. — The treatment is palliative or surgical according to 
the extent of the disease and the severity of the symptoms. Sexual 
intercourse must be controlled, and rest during menstruation insisted 
upon. Hot vaginal douches and regulation of the bowels are routine 
measures in every case. Ichthyol tampons often accomplish unex- 
pected results, especially in the case of tender ovaries which are adher- 
ent in the cul-de-sac. Local galvanism and the fine wire secondary 
faradic current often relieve pain to a marked degree. Pelvic mas- 
sage is useful in the absence of subacute inflammation, or accompany- 
ing pyosalpinx or hematosalpinx. The bromides are indicated to 
allay nervous manifestations. To relieve dysmenorrhcea, the coal-tar 



596 A TEXT-BOOK OF GYNECOLOGY 

derivatives, viburnum compound, and apiol are useful. Opium should 
be used with caution, preferably in the form of codeine. Postural 
treatment during menstruation (raising the hips, or even the Tren- 
delenburg position) sensibly diminishes the throbbing pain due to 
excessive pelvic congestion. Before resorting to operative procedures, 
nonsurgical treatment should receive a fair trial, and an examination 
should be made under anaesthesia in order to determine the extent 
of the disease. 

An ovary adherent in Douglas's pouch may be readily reached by 
vaginal section (preferably through the posterior fornix), freed from 
its adhesions, and examined with a view to the necessity of removal. 
The abdominal route doubtless enables the operator to study the con- 
ditions more intelligently and to separate thoroughly all adhesions. 
Conservative surgery should be practised whenever this is possible, 
especially in cases of cystic hypertrophy. An ovary which is merely 
prolapsed and is not generally diseased may be simply sutured in its 
normal position. There is no object in trying to save one which is 
the seat of general fibroid hypertrophy, with no trace of normal 
follicles. 

When both ovaries are similarly diseased and the tubes are also 
generally affected, it is better to remove the adnexa on both sides, 
especially if the woman has long been sterile. But her wishes must, 
of course, have considerable weight. No fixed rule can be formulated 
to fit every case, as the surgeon must decide for himself regarding the 
extent of the disease and whether the best interests of the patient 
will be served by a conservative or a radical operation. 



CHAPTEE XL 

NEOPLASMS OF THE OVARIES 

Benign neoplasms: Small benign cysts: simple or follicular cysts, cysts of the 
corpus luteum, tubo-ovarian cysts: Neoplastic cysts; proliferating cysts and 
their varieties; dermoid cysts and their varieties: Solid tumours; fibroma, 
calcined tumours — Hematoma — Malignant neoplasms: Primary carcinoma; 
medullary carcinoma; adenocarcinoma; secondary carcinoma: Sarcoma: En- 
dothelioma. 

Neoplasms of the ovaries are of frequent occurrence, and of several 
varieties. There is probably no organ in the body that is so suscep- 
tible to neoplastic changes. These will be considered in the following- 
order : 

Benign Neoplasms : 

1. Small benign cysts: (a) follicular cysts, (b) cysts of the 

corpus luteum, (c) tubo-ovarian cysts. 

2. Neoplastic cysts: (a) proliferating cysts (pseudomucinous 

and serous), (~b) dermoid cysts. 

3. Solid Tumours: (a) fibroid tumours, (b) calcified tumours. 

4. Hematoma. 

Malignant Xeoplasms : 

1. Carcinoma: (a) primary, (b) secondary. 

2. Sarcoma. 

3. Endothelioma. 

Benign Neoplasms 

Small Benign Cysts of the Ovary. — The ovary by reason of its 
peculiar anatomic structure is greatly predisposed to cyst formation, 

and perhaps this tendency is shared by no other organ of the body to 
the same extent. 

The smaller cyst formations have been variously named, as 
hydrops folliculi, hypertrophy of the follicle (Ziegler), small cystic 
degeneration (Hegar), and follicular cysts. 

Slightly dilated follicles and small follicular cysts are distin- 
guished by no essential difference in appearance ; so that the clinician 
is often perplexed to determine what constitutes the degree of cyst 
formation to be designated pathologic. 

597 



598 A TEXT-BOOK OF GYNECOLOGY 

Between the somewhat dilated follicles so frequently met with 
as an accompaniment of chronic oophoritis, and true cysts, no sharp 
dividing line can be drawn, so that frequently a careful histological 
study is necessary before each can be placed in it's proper class. Mar- 
tin (Kranklieiten der Eierstbcke, S. 324) has proposed to regard as 
hydrops folliculi those dilated follicles which reach a size whose diam- 
eter is not greater than the thickness of the normal ovary, and to desig- 
nate as true cysts only those reaching a greater size. Winter {Gynakolo- 
gische Diagnostik, page 174), on the other hand, reserves the term 
cystic, to be applied to those ovaries which reach the size of a 
hen's egg. 

Pathologic cyst formation of the ovary is primarily divided into 
two groups : 

1. Simple or follicular cysts. 

2. Neoplastic cysts. 

To the first group belong (a) follicular cysts; (b) cysts of the 
corpus luteum; (c) tubo-ovarian cysts; while under the second group 
are usually classed (a) proliferating cysts; (b) dermoid cysts. 

Simple or Follicular Cysts. — Various theories have been advanced 
in explanation of the development of follicular cysts, but in the ma- 
jority of instances they are probably due to previous inflammatory 
changes in the ovary, the fibrous tunic of which has become thickened, 
thus preventing the rupture of the follicle, and are therefore reten- 
tion cysts. According to Olshausen, they frequently develop in the 
following manner: In the beginning, the ovary will contain several 

dilated follicles (Fig. 249), which mate- 

jfc**-to«fidQi^l% jt rially increase its size; sooner or later, 

/gtb '$&** ^ ^^^Sw one °^ ^ ne ^ 01i i c l es takes on abnormal 

«^ t rf4^^*^7 m growth and expands on the surface of the 

is *U Wfr ovary in the direction of least resistance. 

\^ jf%> M^L Jin? Pressure from the increasing contents 

V ^S^|%^^~<;4>/ produces atrophy of its wall which be- 

-^— ____^-^ comes thin. When the cyst reaches some 

Fie 249 (WHiTAC RE ).-«In the ^ (p . 2g()) ^ rep l aces the Ovary, 
beginning, the ovary will con- . , , i n P 

tain several dilated follicles."- which has now become flattened trom 
Rothrock. pressure, and appears as a mere thicken- 

ing of the basal wall of the cyst, while the 
peripheral wall of the cyst is thin. As a rule, they develop on the sur- 
face of the ovary, the walls of which are thick and consist largely of 
ovarian tissue. Follicular cysts may be freely movable and even pedun- 
culated or they may develop within the ligament. 

They vary in size from that of a pigeon's egg to that of an orange, 
though, exceptionally, much larger cysts have been met with, reaching 
the size of an adult's head. 

The wall of the cyst varies in thickness, and the external surface 
may be smooth and shining, or rough from adhesions. The inner sur- 
face of the cyst wall is as a rule smooth, shining, and fascialike, 



NEOPIiASMS OF THE OVARIES 



599 



though occasionally a few small wartlike, papillary growths, are ob- 
served springing from the surface. 

Follicular cysts are usually unilocular, though sometimes two or 



remains of partitions or 




more cysts may fuse, in which case the 
trabeculalike forma- 
tions may be seen. 

In the early stages 
of development so 
soon as the follicle 
begins to dilate, the 
ovum dies and the 
membrana granulosa 
undergoes fatty de- 
generation and dis- 
appears. 

The cyst con- 
tents, which repre- 
sent the epithelial 
secretion with per- 
haps some transuda- 
tion from the blood 
vessels, consist of a 
thin clear straw-col- 
oured fluid with a 
specific gravity of 
from 1.005 to 1.026. 
and may at times be 
blood-tinged or turbid. As a rule, the sediment is small, and contains a 
few formed elements consisting chiefly of degenerated epithelial cells, 
fat drops, and at times a few blood corpuscles and cholesterin crystals. 

Histologically, the wall of the cyst is composed of connective tis- 
sue with occasionally some ovarian stroma. The internal surface is 
lined with low cylindrical or cuboidal cells, or it may be without epi- 
thelial lining. 

Cysts of the Corpus Luieum. — The observations of Xagel, Bulius 
and Frankel. prove beyond doubt that cysts may develop in the rup- 
tured as well as in the unruptured follicle. To Eokitansky. however, 
belongs the credit of being the first to describe cysts of the corpus 
luteuni. Like follicular cysts, they are of slow growth and rarely reach 
large size, usually not larger than a walnut, though in a few instances 
they have been observed as large as a foetal head, and, rarely, as large as 
a man's head. They are usually solitary, but two have been observed in 
the same ovary. 

In the beginning, they are usually situated in one or the other pole 
of the ovary (Fig. '251). but as they increase in size they gradually 
replace the ovary, which appears as a flattened mass on the cyst wall. 
Like follicular cysts, they are unilocular, but differ very materially in 



Fig. 250 i Pfa^vn-exstiel t. — -When the cyst reaches some 
size it replaces the ovary." — Kothrock (page 593). 




gOO A TEXT-BOOK OF GYNECOLOGY 

having thick walls made up of two layers, which may be easily sepa- 
rated from each other. The inner stratum, which is called the lutein 
layer, is arranged in folds, and is further characterized by being of a 

} r ellow orange or brown colour. The outer 
layer represents the tunica fibrosa of the 
normal corpus luteum. 

The cyst contents consist, in most 
instances, of a clear serous fluid, which 
is probably the product of transudation 
from the very vascular lutein layer of the 
cyst. Microscopically, they differ widely 
Fig. 251 (Whitacre).— " Cysts of m appearance. In some cysts, the inner 

the corpus luteum ... are usu- , , » , • n -, , , 

ally situated in one or the other stratum 1S ° f ^P 1 ™ 1 COrpuS-luteum struc- 

poie of the ovary."— Rothrock ture, consisting of large epithelioid cells 
(page 599). lying thickly in a scant network of fibril- 

lary connective tissue very rich in capil- 
laries. In a few instances, the innermost layer has been found to con- 
sist wholly of connective tissue (L. Frankel, Archiv fur Gynakologie, 
Bd. lvi, H. 2). 

The recent observations of Orthmann and L. Frankel leave no 
doubt that occasionally cysts of the corpus luteum may be lined by 
epithelium. The character of the epithelium is usually cylindrical, but 
may be cuboidal or approach the squamous type. The cells are not 
always regularly arranged, but may be here and there set diagonally 
to the surface. 

The etiology of these cysts is not known. The frequent coexistence, 
however, of chronic oophoritis suggests that the chronic hyperemia 
incident thereto, may have been the determining cause of the increased 
transudation which gave rise to cyst formation. 

Blood cysts constitute another variety of cysts of the corpus luteum, 
which are not so uncommonly met with, and are of much pathological 
interest and clinical significance. 

Attention has been called to these cysts by certain French writers, 
as Robin, Rollin, Doleris, Petit, and especially Pilliet. 

More recently, Orthmann (Verhandlungen der deutschen Gesellscliaft 
fiir Gyndkologie, 1897) has made a careful and exhaustive study of 
these cysts, and concludes that they originate from hemorrhage into 
the corpus luteum. 

According to Orthmann, these cysts are usually superficial, and 
are most frequently found at one or other pole of the ovary. They 
are round or oval in shape, and vary in size from that of a walnut to 
that of the head of a newborn child. They are frequently firmly ad- 
herent to the surrounding structures and may be bilateral. 

According to Orthmann, it is not always possible to distinguish 
between these blood cysts and primary cysts of the broad ligament 
into which hemorrhage has taken place, and they may be confused 
with ovarian pregnancy. 



NEOPLASMS OF THE OVARIES 



601 




The cyst contents vary. In small cysts, the blood may be coagulated, 
while, in the larger ones, it is usually liquid and of a reddish, dark 
brown, or chocolate colour. On section, one finds the cyst wall composed 
of the characteristic structure of corpus-hit euni cysts (Fig. 252). 

In small as well as in large cysts, the inner wall is uneven and 
more or less strongly folded, and is of a yellow or brown colour. 

The microscopic appearance of the wall of the cyst is, in many 
cases, similar to that of corpus-luteum cysts already described; while, 
in others, there are present many of the histological changes occurring 
in the various stages in the pro- 
cess of regeneration of the normal 
corpus luteum. Like corpus-lu- 
teum cysts, they may sometimes 
be lined with epithelium. 

Tubo-ovarian Cysts. — Cysts 
are occasionally encountered 
which involve both the ovary and 
the Fallopian tube. Various the- 
ories have been advanced in ex- 
planation of such cyst formation, 
but from the great variety which 
have been described, it is evident 
that no one theory will explain 
all cases. It is probable, however, 
that pelviperitonitis with result- 
ing adhesion of the pavilion of 
the tube to the ovary, is primarily 
an important factor in their for- 
mation. The exhaustive studies of Eosthorn have done much to eluci- 
date this subject. He concludes that tubo-ovarian cysts may develop 
from any one of the following conditions, which he divides into two 
groups: The first group includes: 

(a) Cases in which a pyosalpinx becomes adherent to the wall of a 
coexistent abscess of the ovary, with subsequent perforation of the 
wall separating them. 

(o) Adhesion of the pavilion of the tube to the wall of a suppu- 
rating ovarian cyst, with subsequent development of a hydrosalpinx 
and perforation of the cyst into the tube. 

(c) Adhesions of a hydrosalpinx to a papillomatous cyst, with sub- 
sequent perforation of the intervening wall by papillary growths. 

To the second group belong: 

(a) Cases in which a hydrosalpinx becomes adherent to the wall 
of a follicular cyst, with subsequent perforation of the septum. 

(b) Cases in which the fimbria? of a previously diseased tube be- 
come caught in the opening of a ruptured follicle at the moment of 
rupture, and become adherent to the wall of the follicle with the 
development of a tubo-corpus-luteum cyst. 



Fig. 252 f Whitacee). — " On section, one finds 
the cyst wall composed of the character- 
istic structure of corpus-luteum cysts." — 
Eothrock. 



602 



A TEXT-BOOK OF GYNECOLOGY 



While undoubted instances of each of these modes of origin have 
been observed, the classical tubo-ovarian cyst is of follicular origin, 
and only rarely are proliferating cysts communicating with a dilated 
Fallopian tube encountered. 

These cysts are usually unilateral, though they may be bilateral, 
and they vary in size from that of a pigeon's egg to that of a closed 
fist, and, exceptionally, larger ones have been observed.. The junction 
of the tubal portion of the cyst with the cyst proper, is marked by a 
sharp flexion, giving it the peculiar and characteristic appearance of 
a retort (Fig. 213, p. 498). 

As a rule, the larger portion of the cyst is developed from the 
ovary, and is round or oval. The cyst wall is usually smooth, if not 
adherent, and in large cysts may be quite thin. In most instances, 
it is more or less adherent to the surrounding structures. 

Tubo-ovarian cysts are unilocular, and not infrequently they com- 
municate with the uterine cavity, through which the contents are 
periodically emptied. The opening between the ovarian and tubal 
portions of the cyst varies in size, and is frequently guarded by a 
valvelike formation, the remains of the septum (Fig. 253). 

The cyst contents 
consist usually of a clear 
serous fluid similar to 
that of follicular cysts. 
They may, however, be 
turbid, blood-tinged, or 
chocolate - colour from 
disorganized blood. 

Histologically, the 
wall of the cyst is com- 
posed of connective tis- 
sue, while, in the tubal 
portion, atrophied mus- 
cle fibres may be ob- 
served. The epithelial 
lining of the ovarian por- 
tion of the cyst con- 
sists of low cylindrical, cuboidal, or spindle-shaped cells, or may be 
without epithelial lining, while the tubal portion of the cyst is lined 
with cylindrical epithelium which is frequently ciliated. 

Neoplastic Cysts. — Proliferating cysts constitute by far the greater 
proportion of tumours of the ovary. They have been variously desig- 
nated as simple, compound, areolar, unilocular and multilocular, 
colloid and myxomatous cysts, all of which are clinical distinctions 
depending upon their most striking features. Walde}^er divided pro- 
liferating cysts into two groups : Proliferating glandular, and prolif- 
erating papillary cysts, according as they contained papillary growths, 
or not; and this division has been generally followed by most writers 




Fig. 253 (Martin). — "The opening between the ova- 
rian and tubal portions of the cyst ... is frequently 
guarded by a valvelike formation." — Kothrock. 



NEOPLASMS OF THE OVARIES 603 

to the present time. It will be observed that this is a purely clinical, 
and rather vague and indefinite, ground for division, based entirely 
upon macroscopic appearance and admitting of no very sharp dis- 
tinction, since many cysts come under observation in which the char- 
acteristic features of both are present to an almost equal degree. 
The most satisfactory division yet made, and one founded on a chem- 
ical and anatomical basis, and at the same time admitting of marked 
clinical distinctions, is that recently proposed by Pfannenstiel. Leav- 
ing out of consideration mere clinical appearance, Pfannenstiel sought 
to distinguish ovarian cysts by the chemical constituents of their con- 
tents, and found that a large proportion of cysts contained a chemical 
substance long known and formerly called paralbumin and metalbu- 
min. Hammarsten, however, found that it was not an albumin, but a 
substance resembling mucin, which he termed pseudomucin. In a 
smaller, and at the same time clinically sharply differentiated class 
of cysts, Pfannenstiel found that this substance was not present in 
the contents. Carrying his investigation further, he discovered that 
they differed histologically in the character of their epithelial lining. 
In the first group, the cells were cylindrical and resembled mucous 
cells, while in the second group, the cysts were lined by ciliated co- 
lumnar epithelium. He further observed that the two groups differed 
greatly in the gross appearance of their contents. Those of the first 
group were more or less thick, turbid, and often colloid, in appearance, 
while in the other, they were thin, clear, and serous. He therefore 
divided all proliferating cysts into — 

(1) Pseudomucinous cysts. 

(2) Serous cysts. 

Pseudomucinous (Proliferating) Cysts. — To this group belong the 
greater proportion of ovarian cysts. They are usually unilateral, and 
they vary in size from a mere beginning cyst only sufficiently large to 
be recognised, to tumours of enormous dimensions, often filling the 
abdominal cavity, displacing other viscera, and encroaching seriously 
on the thoracic cavity. 

Cartledge has reported (Journal of the American Medical Associa- 
tion, 1897) the largest cyst of the ovary on record. The tumour had 
been growing for thirteen years, and for the last four years very rapidly, 
so that the patient had been unable to assume a reclining posture for 
more than a year and a half. The circumference at the umbilicus was 
79 inches. The woman was 5 feet 4 inches in height and well formed, 
except that she was very much emaciated from carrying this enor- 
mous cyst. Twenty-four gallons of ovarian fluid were removed before 
she was placed in position to be anaesthetized. After that, she was 
placed on her back and 10 additional gallons of fluid withdrawn. The 
adhesions to the anterior parietal wall were terrific. Many ligatures 
were used, and the operation consumed about two hours under unfa- 
vourable circumstances. The woman survived the operation fairly 
well, leaving the table with a pulse of 114. On the fifth day she had a 



604 



A TEXT-BOOK OF GYNECOLOGY 



normal temperature and a pulse of 108. Beginning with the sixth day, 
symptoms of intestinal obstruction developed and she finally died. 
The fluid withdrawn weighed 240 pounds and the sac 5 pounds. 

Other very large tumours have been reported, one successfully re- 
moved by Gilliam, of Columbus, weighing 176 pounds. A. H. Cordier 

has reported a cyst which 
weighed 160 pounds (Fig. 
254). Tumours of 100 
pounds are occasionally 
encountered. 

It is no longer com- 
mon, however, to meet 
with such large cysts, 
inasmuch as surgical aid 
is usually sought before 
the tumour reaches a 
great size. They may 
occur at any period of 
life, from puberty to ad- 
vanced age, although 
they are most frequent- 
ly encountered during 
the childbearing period, 
especially from thirty 
to forty-five. Unmarried 
and sterile women seem 
to be especially predis- 
posed. Whether, as has 
been suggested, preg- 
nancy and lactation by 
temporarily interrupting 
the menstrual function 
afford a protection against 
tumour formation we do 
not know. It is conceiv- 
able, however, that the 
periodical congestion in- 
cident to menstruation, 
may have a determining 
influence. 

The shape of the tu- 
mour is usually spherical, 
ovoid, or irregular in out- 
line. If small, it is usu- 
ally irregular in shape from partial fusion of two or more cysts pre- 
senting no uniformity of structure. Larger tumours, while generally 
assuming a spherical shape, are often uneven in outline, with here and 




Fig. 254. — " A. H. Cordier has reported a cyst which 
weighed 160 pounds." — Kothrock. 



NEOPLASMS OF THE OVARIES 



605 



there nodular prominences due to bulging caused by smaller cysts de- 
veloping in the cyst wall. 

The external appearance of the tumour is pearly white or bluish, 
often smooth and glistening, and at times it has a cartilaginous ap- 
pearance. Over the surface, blood vessels of varying size are fre- 
quently seen ramifying. Occasionally, bands of unstriped muscle 
fibre and the remains of ovarian stroma are to be seen spread out over 
the tumour, especially near the pedicle. 

On section, the tumour will be found to consist of a conglomera- 
tion of a greater or less number of cysts (Fig. 255). Usually, one cyst 
attains a considerable size and constitutes the main portion of the 
tumour, while, in its wall, are developed numerous smaller cysts which 
encroach on the lumen of the main cyst. Sometimes, the entire number 
may be composed of 
a conglomeration of 
innumerable small 
cysts, separated from 
each other by a more 
or less dense struc- 
ture giving it on sec- 
tion a honeycombed 
appearance. Usually, 
the individual cysts 
are separated from 
each other by walls 
of varying thickness 
composed of highly 
vascularized connec- 
tive tissue. These 
septa frequently be- 
come very thin from 
pressure atrophy, and 
may rupture, result- 
ing in fusion of several cysts with intermingling of their contents. Fre- 
quently, the remains of such septa may be seen in the main cyst forming 
trabeculalike processes on its internal surface. Gradually, these septa 
disappear from pressure, and in old or very large cysts, the entire tumour 
may consist of one large space, though usually smaller flattened cystic 
spaces will be found in its walls. The internal surface of the cyst is 
usually smooth, though it may be covered here and there with wart- 
like excrescences, dendritic, or cauliflower growths. These may be few 
or quite abundant. As a rule, the larger the cyst, the smoother will 
be its wall, and the fewer papillary growths it will contain. These 
papillary growths differ much in appearance. They are usually of a 
gray colour, but may be pink or dark red if rich in blood vessels. 

The cyst contents are the product of cell secretion from the lining 
membrane. The contents of the individual cysts composing the 




Fig. 255 (Martin's Handbook). — " On section, the tumour 
will be found to consist of a conglomeration of a greater 
or less number of cysts." — Kotheock. 



606 



A TEXT-BOOK OF GYNECOLOGY 









■gfl^mm 




C&* 3 •'•'-■ J 

t-i 4 






m. 







Fig. 256 ( Veit's Handbook). — " One obtained 
by Pfannenstiel contained a bright trans- 
parent body, probably a degenerated 
ovum." — Eothrock. 



tumour may present the greatest diversity of appearance and consist- 
ence; one obtained by Pfannenstiel contained a bright transparent 
body, probably a degenerated ovum (Fig. 256). In general, they consist 
of a fluid with a specific gravity of from 1.010 to 1.030, of the consist- 
ence of honey, though at times it 
may be thick, ropy, and gelatin- 
ous, especially in the smaller 
cysts. 

In colour it varies quite as 
much as in consistence. It is 
usually turbid, and often has the 
appearance of oily water; it may 
be gray, yellowish, greenish, or 
wine-colour, and sometimes it is 
dark brown from admixture of 
blood. 

Microscopically, it is usually 
poor in organized elements, being 
composed chiefly of a homogene- 
ous mass which may contain a few fat globules, degenerated epithelial 
cells, and, at times, a few red blood corpuscles, hematin and cholesterin 
crystals. 

The cell described by Drysdale and considered by him a pathog- 
nomonic diagnostic sign of ovarian cysts is no longer so regarded. 

The greatest interest attaches to the chemical constituents of the 
cyst contents. They usually consist of a highly albuminous fluid 
which contains in addition a peculiar substance named pseudomucin. 
This substance varies in amount in different cysts, sometimes consti- 
tuting almost the entire cyst contents, and again it is present only in 
small quantities. Small cysts with colloidlike contents are the richest 
in this susbstance. Pseudomucin is a glycoproteid, and differs from 
mucin in not being precipitated by acetic acid. It is further character- 
ized by setting free a copper reducing substance when boiled in the 
presence of dilute mineral acid. 

Test for Pseudomucin. — The following is the test proposed by 
Pfannenstiel and is a modification of Hammarsten's test. To the 
cyst contents is added twice their volume of alcohol after which the mix- 
ture is well shaken. The precipitate is then filtered and well washed 
with alcohol, after which it is gently pressed between filter papers to 
remove the excess of alcohol. A portion of the precipitate is now 
boiled for half an hour in a 10-per-cent solution of hydrochloric acid. 
After cooling, it is treated with phosphorwolfram acid until the albu- 
min is entirely precipitated. The filtrate is filtered and tested with 
Trommer's or Fehling's test for sugar, and if reduction takes place, it 
may be concluded that pseudomucin is present. 

Histologically, the wall of the cyst is made up of three layers. The 
outer represents the tunica albuginea of the ovary, and is covered with 



NEOPLASMS OF THE OVARIES 



607 



germinal epithelium consisting of a single layer of low cylindrical 
cells. The middle layer consists of connective tissue and may contain 
ovarian stroma or smooth muscle fibres. This layer also contains the 
larger blood vessels. The inner layer consists of cyst epithelium and 
is covered by a single layer of peculiar mucuslike cells, cylindrical in 
type. According to Pfannenstiel, these cells show a special affinity for 
hematoxylon and eosin, and by this double stain, the nuclei, cell con- 
tents, and periphery, are clearly differentiated. 

When stained, they appear as high cylindrical cells with small basal 
nuclei, while the cell body consists of a clear transparent mass inclosed 
within the cell wall, which appears as a faint outline. Occasionally, 
the cyst wall contains small ductlike tubes or glands, which originate 
in a proliferation and invagination of the cyst epithelium into the 
wall of the cyst. Frequently, instead of ductlike invaginations, their 
mouths will have become occluded from constriction of the connective 
tissue of the cyst wall, which is also in a state of proliferation, when 
they will appear as small cysts. 
The constant repetition of this 
process of epithelial proliferation 
throughout the tumour, together 
with the increasing contents from 
increased area of epithelial secret- 
ing surface, is responsible for its 
growth (Fig. 257). 

Papillary cysts, according to 
Pfannenstiel, develop in the fol- 
lowing manner: First, a prolifera- 
tion of epithelium takes place 
which causes tilting and displace- 
ment from crowding of the cells, 
carrying with them a thin under- 
lying stratum of connective tis- 
sue; this, being rich in blood ves- 
sels, also takes on proliferation. In many instances, the connective- 
tissue proliferation appears to surpass the proliferation of the epithe- 
lium, which must, however, always be considered primary. 

Serous {Proliferating) Cysts. — Serous cysts are much less common 
than the pseudomucinous variety, occurring in the proportion of about 
1 to 8 of the latter. As a rule, they are small, and never reach the 
enormous dimensions of pseudomucinous cysts, although cysts the size 
of a pregnant uterus at term have been observed. 

In external appearance, they resemble somewhat pseudomucinous 
cysts. In contrast with pseudomucinous cysts they frequently develop 
bilaterally. While they may lie free in the peritoneal cavity, attached 
by a well-formed pedicle, they frequently develop within the folds of 
the broad ligament, and show a special tendency to become attached 
to the neig-hbouring viscera bv adhesive bands. 




Fig. 257 (Whitacre).— Epithelium of a 
pseudomucinous cyst. — Kothrock. 



608 



A TEXT-BOOK OF GYNECOLOGY 



On section, these cysts are also multilocular, though, as a rule, they 
seldom contain so many cysts as the pseudomucinous variety. A cer- 
tain proportion of serous cysts, especially the larger ones, may appear 
macroscopically as unilocular cysts, but microscopic examination will 
invariably reveal the presence of small cysts within the walls of the 
tumour. As a rule, these cysts contain papillary growths, and they 
represent the type of proliferating papillary cysts of the old classifica- 
tion, just as the glandular type is represented by the pseudomucinous 
variety. Occasionally, however, serous cysts may be of the glandular 
type and contain no papillary growths. 

Papillary growths may be very abundant, and may completely fill 
smaller cyst cavities, and even cause rupture by pressure from in- 
creased contents, or they may grow through the wall of the cyst caus- 
ing perforation. Not in- 
frequently, serous cysts 
are encountered with 
papillary growths on 
their surface as well as in 
their interior (Fig. 258). 
These may grow direct 
from the germinal epi- 
thelium, or may repre- 
sent a continuation of 
intracystic papillary 
growths which have 
penetrated the wall of the 
cyst. Such cysts are al- 
most invariably accom- 
panied by ascites. 

The contents of se- 
rous cysts consist of a 
thin, clear, straw - col- 
oured or greenish fluid, 
rich in albumin but con- 
taining no pseudomucin. It is partly derived from cell secretion and 
partly from transudation from the blood vessels. 

Histologically, the wall of serous cysts, as of pseudomucinous cysts, 
is composed of three layers, differing only in the inner layer which is 
lined by columnar ciliated cells. The papillary growths often present 
on microscopical section the most picturesque forms, usually consist- 
ing of rather scant connective-tissue stalks with branching processes 
extending in every direction from the main trunk (Fig. 259). The epi- 
thelium covering the papillary growths is the same as that lining the 
cyst. Not infrequently, deposits of lime salts are to be seen in the 
papillomatous growths, often presenting a concentric layer arrange- 
ment; they are termed psammoma. 

Superficial Papilloma of the Ovary. — Occasionally, noncystic ovaries 




Fig. 258. — " Serous cysts are encountered with papillary 
growths on their surface." — Eothrock. 



NEOPLASMS OF THE OVARIES 



609 



are covered with papillomatous growths, which are similar in their 
gross appearances and anatomic structure to those found in cysts. 
Frequently, they completely cover the ovary, so that it appears as a 
papillomatous mass which may 
reach the size of an orange. These 
growths may originate from per- 
foration of small cysts which be- 
come filled with papillomatous 
growths and afterward spread over 
the surface of the ovary; or they 
may grow directly from the ger- 
minal epithelium, which is perhaps 
the more common mode of origin. 
They are frequently bilateral, or 
may occur in company with a papil- 
lomatous cyst of the other ovary. 
Histologically, their structure does 
not differ from that of papillary 
growths occurring in cysts. They 
are invariably covered with ciliated 
epithelium. 

Histogenesis. — The origin of 
proliferating cysts of the ovary is 
still a matter of much controversy, 
although the investigations of 
many competent observers in re- 
cent years, have done much to 
throw light upon this obscure sub- 
ject. Formerly all ovarian cysts 
were believed to originate in the 




Fig. 259 (Whitacre). — "The papillary 
growths often present on microscopical 
section the most picturesque forms." 
— Kothrock (page 608). 



Graafian follicle. Virchow, after 

a careful investigation of colloid 

cysts, concluded that the}^ were of 

connective-tissue origin, the result 

of colloid degeneration of the stroma of the ovary, and that the colloid 

mass constituting the cyst contents was the product of degeneration. 

The excellent work of Klebs and AYaldeyer in determining the 
epithelial origin of cysts, has placed the subject of histogenesis on a 
firm basis. They advanced the theory that proliferating cysts origi- 
nated from Pfliiger's tubes. More recent investigations have shown, 
however, that epithelial neoplasms have their origin, not in the em- 
bryonal Pfliiger's tubes, but in tube or glandlike formations occasioned 
by a tilting in, and subsequent invagination of, the germinal epi- 
thelium into the ovarian stroma, which from the beginning must be 
regarded as neoplasms. According to Pfannenstiel, this dipping in of 
the germinal epithelium is not to be considered in the same light with 
embryonal misplaced epithelium in the sense of Cohnheim's theory, 
40 



610 A TEXT-BOOK OF GYNECOLOGY 

but rather as the result of certain pathologic changes which the ger- 
minal epithelium undergoes. Until comparatively recently, the ger- 
minal epithelium was considered the sole source of proliferating cysts, 
but evidence begins to accumulate that they may, and often do, origi- 
nate in the Graafian follicle. 

The careful researches of Flaischlen, Bulius, Steffeck, Frommel, 
Pfannenstiel, Williams and others, seem to prove beyond doubt, that 
under certain conditions the membrana granulosa of the follicle may 
undergo pathologic change and be replaced by cylindrical epithelium, 
from which cysts may develop in a manner analogous to those devel- 
oping from the germinal epithelium. Williams, after an exhaustive 
study of the histogenesis of papillary cysts, concludes: (1) that the 
Graafian follicle is probably the usual starting point of papillary cysts, 
and, according as the membrana granulosa is transformed into cili- 
ated epithelium or not, so will the cyst be lined with ciliated or non- 
ciliated epithelium. (2) That the germinal epithelium is perhaps the 
most frequent source of superficial and multilocular papillary cysts. 

On the other hand, Pfannenstiel has shown that serous or ciliated 
cysts may develop from the germinal epithelium, it having first under- 
gone pathologic change, becoming ciliated ; and he regards this as the 
usual orgin of such cysts, while von Velits entertains the view that 
most ciliated cysts have their origin in the Graafian follicle. 

According to Pfannenstiel, pseudomucinous cysts usually originate 
in the Graafian follicle. 

The theory advanced by Marchand, that ciliated cysts may origi- 
nate from tubal epithelium, still remains to be proved. To sum- 
marize, therefore, it may be said that both pseudomucinous and 
serous cysts may have their origin in the germinal epithelium or in the 
Graafian follicle. 

Metastasis. — Both varieties of proliferating cysts may give rise to 
metastasis. While pseudomucinous cysts are usually classed with be- 
nign tumours, occasionally metastases have been observed, especially 
occurring in the peritoneum, which must be regarded as implantation 
metastases. They have most frequently been noted in cysts with 
papillary growths, and they tend to develop underneath the peri- 
toneum in the form of cystic growths containing gelatinous masses, 
and have been termed pseudomyxoma peritonei (Werth). They most 
frequently follow spontaneous rupture of cysts, thus allowing the cyst 
contents to escape into the peritoneal cavity, though they have been 
observed to follow operation for the removal of cysts, when they must 
be regarded as implantations occurring at the time of operation. 

Various explanations have been advanced in explanation of im- 
plantation metastasis, but it is generally believed that it takes place 
at points where, from irritation, as from pressure or operative pro- 
cedures, the endothelial lining of the peritoneum has been destroyed. 
These metastases are possessed of no special degree of malignancy, 
but are particularly prone to recur after removal. 



NEOPLASMS OF THE OVARIES (311 

Metastasis is much more frequently observed to follow serous cysts. 
The glandular form is benign and does not tend to recur after removal 
or to give rise to metastasis. The papillary form, however, is particu- 
larly characterized by the tendency to metastasis which occurs, accord- 
ing to Pfannenstiel, in the proportion of about 13.3 per cent. Metas- 
tases almost invariably occur in the peritoneum, and appear as 
superficial cauliflower growths. They are very persistent, and only 
complete and thorough removal by radical operation will effect a cure. 

Malignant Degeneration. — Both varieties of ovarian cysts may un- 
dergo malignant degeneration. From the epithelial elements, carci- 
noma may have its origin, while sarcoma may begin in the connective 
tissue of the wall of the cyst. A cyst can only be said to have under- 
gone carcinomatous degeneration when the carcinoma is localized in 
small areas while the remainder of the tumour presents no evidence 
of malignancy. In case the carcinomatous process is widespread, the 
tumour must be classed as primarily carcinoma. (See Carcinoma of 
the Ovary.) 

Sarcomatous degeneration of the wall of ovarian cysts has been 
only rarely observed. Cases have been reported by Pfannenstiel, E. 
Frankel and Kelly. It may occur in the form of a nodule or as a dif- 
fuse infiltration of a considerable area of the cyst wall. 

Dermoid cysts, as the name implies, are tumours containing struc- 
tures resembling skin. They are the least frequent of ovarian cysts, 
occurring, according to Olshausen, in the proportion of about 3.5 per 
cent. They are usually small, seldom reaching a size larger than a 
man's head. They are commonly unilateral, though bilateral tumours 
are by no means infrequent. Gebhard, among 107 cases, found 16 
bilateral. In most instances, they present a smooth external surface, 
though they may be irregular in outline and be attached to the sur- 
rounding structures by adhesions. Generally they are attached by a well- 
formed pedicle, and only rarely do they develop within the folds of the 
broad ligament. In the majority of instances, they appear as simple 
cysts, though close examination will frequently reveal the remains of 
septa or small cysts within the tumour walls. 

The cyst contents vary in consistence. In pure dermoid cysts they 
consist of an oily fatty substance, frequently resembling vernix caseosa, 
which thickens on cooling. It often contains loose hair, which is 
usually rolled in balls, besides caseous masses that are accumulations 
of sebaceous matter (Fig. 260). 

On section, a typical dermoid cyst is unilocular. More frequently, 
however, dermoid cysts are combined with proliferating cysts in which 
one or more of the cyst cavities contain dermoid structures. Accord- 
ing to Pfannenstiel (Veit's Handbuch, vol. iii, p. 366), they are most 
frequently combined with pseudomucinous cysts, and very rarely with 
serous papillary cysts. 

The outer layer of the cyst wall is fibrous and usually thin, while 
the inner layer consists of a structure resembling skin, from which 



612 A TEXT-BOOK OP GYNECOLOGY 

are frequently found growing appendages of the skin, as hair, teeth, 
occasionally nails; and in them are developed sweat and sebaceous 
glands (Fig. 261). 

Between this layer and the outer cyst wall, is usually found a struc- 
ture resembling adipose tissue, which consists largely of fat and con- 




Fig. 260. — " It often contains loose hair . . . besides caseous masses." — Rothrock (page 611.) 

nective tissue; in it are often found bone, smooth muscle, more rarely 
nervous tissue, cartilage, and, in a few instances, glandular structures 
resembling the mammary and thyroid glands have been observed. Very 
rarely, structures corresponding to the intestinal or respiratory tract 
have been observed. In these structures, Wilms has recognised an 
attempt at reproduction of the three embryonal layers — namely, those 
growing from the ectoderm including skin and appendages; those 
from the mesoderm consisting of fat, connective tissue, bone, muscle 
and nervous tissue; and endodermal structures resembling intestines 
and respiratory tract. 

As a rule, dermoid structures are found only in a small area of 
the cyst wall appearing as a nodular raised prominence, which is 
covered with hair and may contain teeth or bone. The hair in der- 
moid cysts is as a rule short, though it may, rarely, reach a length of 
several feet. It is usually of a reddish brown or blonde colour, which 
is uniform throughout the cyst. Teeth are usually irregularly shaped, 
often rudimentary, and as a rule only a few are present, though as 
many as 300 have been reported. They are generally incisors or molars, 
and are set with their crowns pointing toward the axis of the body. 
Not infrequently, they are set in bone resembling rudimentary jaws. 
The bones found in dermoid cysts simulate those which lie in positions 
near hair-covered skin, as the maxillary bones, bones of the cranium, 



NEOPLASMS OF THE OVARIES 



613 



or pubic bones. Less frequently, bones resembling long bones have 
been observed, such as ribs, phalanges of fingers or toes, and even joint- 
like formations with cartilaginous covering have been described. 
Barely, brainlike formations have been observed, and in a few instances, 
also, structures simulating the eye. with retinal pigment. 

Histologically, dermoids are of the greatest interest from the won- 
derful variety of structures they contain. Almost every tissue or organ 
in the body may find its prototype in the structures of a dermoid 
cyst, though often, it is true, in a more or less rudimentary state. 

Until comparatively recently, the theory most generally accepted in 
explanation of the origin of dermoids, was that of inclusion. At the 
present time, the ovulogenous theory, proposed by Wilms, finds most 
adherents. In proof of its correctness, there has been advanced the 
finding of structures in dermoids, corresponding to the three em- 




Fig. 261 | Gebhakd). — •• In them are developed sweat and sebaceous glands." — Kothrock 

ipage 612). 



bryonal layers, which is characteristic of ovarian dermoids alone, as 
compared with those occurring in other regions of the body. In further 
support of this theory, the fact that they are sometimes met with 
in the foetus makes it appear that they have their beginning in early 
life, and that the ovum possesses all the requisites necessary for the de- 
velopment of the many structures present in dermoid cysts. 



6U 



A TEXT-BOOK OF GYNECOLOGY 



Malignant Degeneration. — Dermoid cysts may undergo sarcomatous 
or carcinomatous degeneration (Fig. 262). Sarcoma usually develops in 
the wall of the cyst. 

Well-authenticated carcinoma beginning in dermoids has been ob- 
served in a few instances. It was formerly believed that it was always 

epidermal in charac- 
ter. Kecently, how- 
ever, Yamigiva found 
a glandular carci- 
noma Avhich he be- 
lieved to have origi- 
nated in a pseudo- 
mammary gland. 

Teratoma. — Tera- 
tomata are tumours 
closely related to der- 
moids in their his- 
togenesis, but differ- 
ing in their struc- 
ture and appearance. 
They are very rare, 
as compared with 
dermoids, and are 
solid tumours, or are 
at least made up 
largely of solid struc- 
tures. They are usu- 
ally unilateral and may reach enormous size. The tumour consists of a 
conglomeration of embryonal elements resting on a fibrous structure, 
or stroma, which is rich in blood vessels. They are inclosed in a 
fibrous capsule, in which may, at times, be found the remains of 
ovarian stroma. Histologically, they contain the same embryological 
elements as dermoids. 

Solid Tumours. — Fibroma of the Ovary. — Fibroma belongs to the 
rarer ovarian tumours, its frequency being, according to the estimate 
of Pfannenstiel, between 2 and 3 per cent. It is probable that a num- 
ber of tumours heretofore described as fibroma were in reality fibro- 
sarcoma. 

As a rule, their surface is smooth, though often irregular in outline, 
and they are usually attached by a pedicle, but may develop within the 
ligament (Fig. 263). They are usually unilateral, though they may be 
bilateral. In size, they vary from that of a walnut to that of a man's 
head, and may rarely weigh as much as 30 or 40 pounds. Usually no 
ovarian structure can be recognised. They vary in consistence. When 
the tumour consists of pure fibroma it is firm. Occasionally, the tumour 
may be cystic from the presence of dilated lymph or blood vessels, or 
cystic cavities may result from degeneration or necrosis. 




Fig. 2632.- 



-" Dermoid cysts may undergo . . 
defeneration." — Roth rock. 



carcinomatous 



NEOPLASMS OF THE OVARIES 



615 



Fibroid tumours of the ovary may undergo fatty or myxomatous de- 
generation, or contain calcareous deposits. 

Histologically, they are composed of fibrillary connective-tissue 
bundles which run in all directions, and smooth muscle fibres may 
be present, though as a 
rule they are scanty 
(Fig. 264). 

Barely, combinations 
with other tumours are 
observed, as with ade- 
noma and sarcoma, and 
the former may degener- 
ate into carcinoma or 
develop cystic cavities 
containing colloid sub- 
stance. When smooth 
muscle is present, the 
tumour is properly 
termed fibromyoma. A 
few cases of pure myoma 
of the ovary have been 
described, but they are 
very rare. 

Calcified tumours of 
the ovary have been ob- 
served from time to 
time; they have general- 
ly been regarded as oste- 
omata, but the careful 
investigations of Whit- 
ridge "Williams have established the fact that they contain no bony 
tissue. Schlenker published a description of this condition about the 
middle of the eighteenth century, and was followed a few years later 
(1760) by Le Clerc de Beaucoudray. with a description of an ossified 
ovary. From that time until the present, numerous similar descriptions 
have appeared, all of them obviously based upon the original miscon- 
ception as to the true character of the growth. The process of calcifica- 
tion may (a) occur in the ovarian stroma; or (b) be restricted to the 
Graafian follicle. 

Calcareous Tumours of the Ovarian Struma. — These growths, if 
such they may be called, are generally small, the ovary containing them 
rarely exceeding 7 centimetres in its longest diameter. In one case 
examined by Williams the ovary revealed many cicatrices, but no 
adhesions, upon its surface. On section, one end was found to be occu- 
pied by a hard roundish nodule 12. 16. and 18 millimetres in its various 
diameters (Fig. 265). This nodule occupied an apparent capsule with 
which it was connected bv numerous connective-tissue bands. On 




Fig. 263 (Martin |. — "As a rule, their surface is smooth, 
though often irregular." — Kothrock i page 614). 



616 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 264 (Whitacre).— " They are composed 
of fibrillary connective - tissue bundles 
which run in all directions." — Rothrock 
(page 615). 



sawing through the nodule, which was of bony hardness, its cut sur- 
face presented a mottled appearance and the general colour of bone. 
At one side of the ovary were found the corrugated walls of an old 
corpus luteum, about 13 millimetres in diameter. Here and there were 

seen several follicles with clotted 
contents. On the other side, the 
ovary revealed a hard large nod- 
ule measuring 7, 6, and 5 centi- 
metres in its various diameters. 
From the anterior and inner sur- 
face of the ovary there developed 
a number of small pedunculated 
fibromata, the largest being 6 
millimetres in diameter. From 
the neighbourhood of these small 
fibromata, the ovarian tissue cov- 
ering the hard nodule began to 
decrease in thickness, soon be- 
coming as thin as a sheet of pa- 
per. This thin capsule was per- 
forated in a number of places, 
through which perforations the 
surface of the hard mass was visi- 
ble. This mass weighed 220 grammes, was extremely hard, and re- 
sembled ivory in its general consistence. When thrown upon a hard 
surface it rebounded like a billiard ball. On section, its surface was 
mottled, presenting an appearance similar to that of the smaller nodules 
of the other ovaries. 
Dry sections of both 
masses revealed no 
trace of bony struc- 
ture. Microscopical 
sections made after 
decalcification by a 
10-per-cent solution 
of nitric acid, 
showed that both 
masses were iden- 
tical in structure. 
They were composed 
of typical fibrous tis- 
sue made up of bun- 
dles of dense connective tisuse, which interlaced in all directions, and 
possessed but few long nuclei. The tissue resembled that found in the 
hilum of the ovary, except that it was poorer in blood vessels, and con- 
tained more veins than arteries. Scattered all through it, were irregu- 
lar-shaped areas of various size, which stained deeply with hematoxylin. 




Fig. 265. — " On section, one end was found to be occupied by 
a hard roundish nodule. 1 '— Reed (page 615). 



NEOPLASMS OF THE OVARIES 617 

They generally presented sharply marked contours, and, in their in- 
terior, revealed signs of striation, but no trace of nuclei could be found 
within them. Here and there, under a high power, could be seen 
individual cells which had lost their nuclei and presented the typical 
appearance of coagulation necrosis. Single cells, each containing a 
calcareous granule, and others which were entirely calcified, were ob- 
served. The general mass had manifestly developed by a process of 
cell coalescence. 

Calcareous tumours of the corpus luteum have been observed by 
Bland Sutton, Coe and others. Coe's case was examined and reported 
upon by Whitridge Williams substantially as follows: The ovary was 
5 centimetres long and 2.5 centimetres deep; on its surface were 
numerous cicatrices but no adhesions; in its centre was a hard mass 
12 millimetres in diameter, of bonelike consistence. When sawn 
through, it was seen to consist of two portions, a soft pinkish central 
portion, and a hard bonelike outer portion, 2 millimetres thick, and 
of a distinctly yellow colour. The central portion of the nodule re- 
sembled partially organized blood clot. The rest of the ovary presented 
a normal appearance. Microscopic examination after decalcification 
and section of the mass, revealed no signs of osseous structure. The 
decalcified sections stained poorly, but the hard exterior of the nodule 
stained readily with hematoxylin and presented a more or less homo- 
geneous granular appearance, in which it was impossible to distinguish 
nuclei. This tissue was surrounded by typical ovarian stroma, which 
also stained poorly. The central portion of the nodule was composed 
of dense fibrous tissue which was very poor in cells. Between this and 
the decalcified portion, were layers of small cells, possibly corresponding 
to the membrana granulosa, though it is impossible to state their origin 
with certainty. In the surrounding ovarian stroma were numerous 
round stellate crystals, which were thought to be the result of the 
decalcification. The specimen was looked upon by Williams as in all 
probability representing a calcification of the large ceils which sur- 
round a ripe Graafian follicle and form the yellow margin of the 
corpus luteum. 

The causes of calcification within the ovary probably do not differ 
in general from those producing that condition in other parts of the 
body. The deposit of calcareous salts, first, in foci which, coalescing, 
form the larger masses, is recognised by Cohnheim, Litten, and Whit- 
ridge Williams, as following only certain varieties of necrosis, par- 
ticularly those characterized by coagulation. The calcification of ne- 
crotic areas is explained by the chemical affinity which exists between 
the necrotic tissue and the calcium salts circulating in the blood, prob- 
ably as a soluble albuminate. It is assumed that the soluble albumi- 
nate, by virtue of chemical affinity, mingles with the material of the 
dead cells forming an insoluble albuminate of lime which is deposited 
in them. That this general law of calcification is operative within the 
ovary, becomes apparent when it is remembered that that organ is liable 



618 A TEXT-BOOK OF GYNECOLOGY 

to fibroid changes, to displacements, and to other mechanical interfer- 
ence with its circulation, all of them calculated to induce more or less 
cell necrosis. 

The symptoms of calcareous tumours of the ovary are in no sense 
characteristic. The diagnosis of this condition has probably never been 
made before operation. There is, therefore, no special treatment, other 
than that which applies to other solid tumours of the ovaries. When 
discovered they should be removed. (See Ovariotomy.) 

Hematoma of the Ovaries. — Follicular hemorrhage is of common 
occurrence, being due to the rupture of vessels in the wall of the 
ovisac. But the term hematoma is usually applied clinically to 
tumours above the size of a hazelnut. In the case of hemorrhage into 
a follicular cyst, they may reach the size of a small orange. While 
excessive hyperemia of the ovary may lead to interstitial hemorrhage, 
so-called apoplexy of the gland is probably always secondary to rup- 
ture of a follicular hematoma. 

Causes and Pathology. — Venous stasis leading to the rupture of 
veins in the walls of dropsical follicles may be due to pelvic conges- 
tion from any cause, such as sexual excitement or excess. Its occur- 
rence in connection with neoplasms, ectopic gestation, and abortion, 
is similarly explained. Hematoma is often associated with tubal dis- 
ease, especially when there are many adhesions or torsions of the 
pedicle. General follicular hemorrhage and apoplexy have been noted 
as the result of profound alteration of the blood in extensive burns, 
phosphorus poisoning, and in the acute exanthemata. An ovary 
which is the seat of general follicular hemorrhage, is enlarged to two 
or three times its normal size, dark red nodules as large as a pea or 
marble appearing on its surface. On section, these are seen to be cir- 
cumscribed collections of semifluid blood or coagula in various stages 
of absorption. Or a single tumour may include almost the entire 
ovary, only a small portion of the stroma remaining. The usual 
changes occur in the blood until only a clot or mass of fibrin is found. 
The cyst may become infected through its proximity to the gut or 
Fallopian tube. The internal pressure may become so great that it 
ruptures, and an intraperitoneal hematocele develops ; but it is doubt- 
ful if sufficient blood ever escapes to endanger life. 

Symptoms and Diagnosis. — In spite of the statements in text- 
books, it is questionable if the symptoms of ovarian hematoma are suf- 
ficiently characteristic to warrant a positive diagnosis; in fact, the 
condition is usually found on opening the abdomen for supposed in- 
flammatory disease. The sudden occurrence of severe throbbing pain 
in the region of the ovary, with marked enlargement and tenderness, 
but without rise of temperature, in connection with conditions leading 
to excessive pelvic congestion, would point to a rapid effusion of blood 
into a follicle. The sudden enlargement of a pre-existing cystic ovary 
would be still more significant. Should the cyst rupture, the usual 
symptoms of intraperitoneal hemorrhage would develop, though it 



NEOPLASMS OP THE OVARIES 619 

would be exceedingly difficult to diagnosticate it from early rupture 
of an ectopic sac. After the acute stage, or in cases of slow oozing, 
the symptoms are those common to ovarian disease, and are often 
masked by those of localized peritonitis. 

Treatment. — The treatment of acute hemorrhage consists in rest, 
ice^bags, low diet, regulation of the bowels, and the avoidance of any 
influences tending to increase pelvic congestion. True hematoma of 
the ovary is a surgical condition, and calls for removal of the affected 
ovary, or of the blood sac alone if a portion of healthy stroma can 
be preserved. 

Malignant Neoplasms 

Primary carcinoma of the ovary is the most common form of ma- 
lignant disease of the ovary. While varying greatly in form and 
appearance, it admits of division into two groups, each of which is 
represented by a more or less distinct type. 

Group I. Medullary Carcinoma. — The first group consists of solid 
tumours. They are of more or less firm consistence, usually rounded 
or oval in shape, though often irregular in outline, and frequently 
present a nodular or lobulated appearance. They vary in size, rarely, 
however, exceeding that of the head of a newborn child. As a rule 
they form their attachment by a short thick pedicle, and usually they 
lie free in the abdominal cavity; only very rarely have tumours been 
observed which were partially intraligamentary. Not infrequently, 
they are bilateral though unilateral development is the rule. 

They are inclosed in a dense fibrous capsule, and, on section, pre- 
sent a more or less homogeneous surface of yellowish or gray white 
colour (Fig. 266). Frequently, in softer tumours, the appearance is 
brainlike. Occasionally, the tumour will 
have a mottled appearance from extravasa- 
tions of blood into the tumour substance, 
which, if recent, may be coagulated, or if 
of long standing, may appear as an extrav- 
asation cyst simulating those often found 
in cerebral hemorrhage. Degeneration 
changes are of common occurrence, espe- 
cially caseous and fatty changes, with re- 
sulting softening and the formation of 
cystlike cavities. The contents of such 

J . , . .. -. „ Fig. 266 (Gebhard).—" They are 

cysts are turbid and of a yellowish colour, inclosed in a dense fibrous cap . 
while their walls present an irregular and sule."— Kothrock. 
uneven outline. Histologically, they are 

composed of a more or less diffuse infiltration of a fibrous stroma with 
carcinomatous cells. In some instances, the fibrous stroma predomi- 
nates, forming alveoli which are filled with carcinomatous cells. More 
frequently, however, the microscopic appearance is that of a diffuse 
infiltration of the rather sparse fibrous stroma, so that the cellular ele- 




620 



A TEXT-BOOK OF GYNECOLOGY 



ment constitutes the greater part of the tumour, in which case it is 
termed medullary carcinoma. 

Group II. Adenocarcinoma. — The second group consists of cystic 
tumours which bear a striking resemblance in their external appear- 
ance to serous cysts. They are rounded or oval tumours, and rarely 
exceed in size an adult's head, being usually smaller. They are gen- 
erally attached by a short pedicle, though they may develop within the 
ligament, and are frequently adherent to the surrounding viscera. 
Like serous cysts, they are often bilateral and are usually multilocular, 
though they may at times appear unilocular. 

According to Pfannenstiel, papillary growths are observed on the 
external surface of the cyst in about half the cases. On section, the 
cyst wall is composed of connective tissue which is often quite friable. 
Frequently the wall of the cyst is very much thickened in spots from 
the development in it of carcinomatous nodules. Growing from the 
internal surface, may usually be seen papillary and cauliflower growths 
at times almost filling the cyst cavity. The cyst contents may be 
clear, but more frequently they are turbid from the presence of cellu- 
lar elements, or they may be blood-tinged from hemorrhage into the 




Fig. 267. — " Cystic carcinoma of the ovary is almost invariably papillary." — Eothrock. 

cyst. Cystic carcinoma of the ovary is almost invariably papillary 
(Fig. 267). The papillary growths are often similar in appearance to 
those of the papillary cysts, still, on section, their carcinomatous nature 
may often be recognised by the naked eye. 

Histologically, they belong to the adenocarcinomata, and often the 
same tumour presents a great variety of structure. The solid masses, 



NEOPLASMS OF THE OVARIES 



621 



which are found in the wall of the cyst, may consist of a diffuse infil- 
tration of a medullary character. More frequently, however, such 
nodules and cauliflower growths are not really solid but are made up 
of papilla and glandlike formations, the lumen of which is still plainly 
visible. Everywhere an atypical proliferation of epithelial cells is 
present, and in papillary growths, instead of being covered with a 
single layer of cells as 
in cystadenoma, the epi- 
thelium will be replaced 
by several layers of cells 
asymmetrically arranged 
(Fig. 268). The same 
peculiarity is observed in 
the glandlike formations 
in which, instead of be- 
ing lined with a single 
layer of cells, the lumen 
will frequently be filled 
with a proliferation of 
cells giving it an alve- 
olar appearance. 

Not infrequently, 
lime salts become depos- 
ited, especially in the 
papillary growths, with 
the formation of psam- 
moma. Between cystad- 
enoma (Fig. 269) and this type of primary carcinoma, every gradation 
exists, and so gradual is the transition that it is not always possible to 
distinguish between them. Ziegler (Pathologisclie Anatomie, page 335) 
admits that no sharp dividing line can be drawn between adenomata 
which are benign and those which are malignant. 

Pfannenstiel estimates that fully one half of all papillary tumours 
of the ovary belong to the carcinomata, but, according to his view, 
almost all cases which ultimately become carcinomatous should be 
classed as primary carcinoma. The adenoma from which the carci- 
noma develops, he regards as representing an intermediary stage, but 
at the same time he admits that there is no means of distinguishing 
it from benign adenoma. Most authors, however, take a middle 
ground, and regard a considerable number of such tumours as carcino- 
matous degeneration of primary benign tumours. 

The microscopic evidence of malignant change consists in a pro- 
liferation of the epithelial cells with atypical arrangement, as, for 
example, instead of the uniform single layer of epithelium are to be 
seen masses of cells, asymmetrical in their arrangement, and tending 
to form several layers (Fig. 270). 

Metastasis is of frequent occurrence, tending to involve first of 




Fig. 268 (Whitacre). — "Everywhere an atypical prolif- 
eration of epithelial cells is present. 11 — Eothrock. 



622 



A TEXT-BOOK OF GYNECOLOGY 



all the peritoneum, next the omentum, liver, stomach, intestine, and 
occasionally, the pleura. Where the disease is unilateral, the ovary on 
the opposite side is frequently the seat of metastasis, and Steffeck has 
often found it to contain metastatic deposits, when macroscopically it 




Fig. 269 (Whitacre). — Cystadenoma. — Eothkock 



appeared normal. Heinrichs observes, also, that bilateral develop- 
ment is commonly the result of metastatic involvement from one 
ovary to the other. 

Secondary carcinoma of the ovary is rare, and usually follows car- 
cinoma of the uterus, especially of the body. It has, however, been 
observed to follow carcinoma of the stomach and mammary gland, the 
result of metastasis. Like other epithelial neoplasms of the ovary, 
primary carcinoma may have its origin in the Graafian follicle or in 
the germinal epithelium. 

Sarcoma of the ovary is of much less common occurrence than car- 
cinoma. Cohn estimates the frequency as compared with ovarian 
cysts at 1 per cent, and as constituting 10 per cent of malignant 
tumours of the ovary. On the other hand, Pfannenstiel, in 400 ovari- 
otomies, found sarcoma of the ovary in the proportion of 5.38 per 
cent. With these, however, he included endothelioma. 

Primary sarcoma of the ovary may occur at any period of life, in 
childhood as well as in advanced age, and Doran has observed it in- 



NEOPLASMS OF THE OVARIES 



623 




volving both ovaries of a seven months' foetus. It appears to be more 
frequently met with, however, between the ages of twenty and thirty. 
It is frequently bilateral, though, as Heinrichs observes, this may 
sometimes be the result 
of metastasis, only one 
ovary having been pri- 
marily involved. 

Sarcoma belongs to 
the solid tumours of the 
ovary, and is usually 
rounded or cylindrical in 
shape with a smooth sur- 
face, though it may be 
irregular in contour, pre- 
senting a nodular appear- 
ance. The size of the 
tumour varies and may 
sometimes reach a weight 
of 20 to 30 pounds or 
more, if left to run its 
course without surgical 
intervention. Usually, 
however, the presence of 
the tumour is manifested 
by symptoms before it 

attains a great size. The consistence of the tumour depends upon its 
histologic structure. If made up largely of spindle cells, it will be 
firm, resembling fibroma, whereas, if composed chiefly of round cells, 
it will be soft, and often of brainlike consistence. Frequently, these 
tumours contain much fibrous tissue, when they are called fibrosar- 
coma. 

Usually, the entire ovary is replaced by the tumour mass, though, 
occasionally, the remains of ovarian tissue may still be seen on its 
surface. The tumour is commonly surrounded by an outer wall, 
which is in many instances so thin and delicate that the fingers may 
be thrust through it. These tumours are usually attached by a short 
pedicle, and are seldom adherent to the neighbouring viscera, but are 
frequently accompanied by ascites. On section, they represent a yel- 
lowish white, gray, or pink surface, the colour depending on their 
structure and blood supply. Cyst formations are by no means infre- 
quent, and are usually the result of hemorrhagic infarcts or extrava- 
sations of blood into the tumour substance with subsequent soften- 
ing, or of fatty degeneration of the tumour cells. Histologically, 
sarcoma consists of a diffuse infiltration of the ovarian stroma by sar- 
coma cells, the variety most commonly found being round or spindle 
cells (Fig. 271). Frequently both round and spindle cells are present in 
the same tumour. 



Fig. 270 (Whitacre). — "The microscopic evidence of 
malignant change consists in a proliferation of the 
epithelial cells with atypical arrangement." — Roth- 
rock (page 621). 



624 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 271 (Whitacbe). — u Sarcoma consists 
of a diffuse infiltration of the ovarian 
stroma by sarcoma ceils." — Eothrock 
(page 623). 



In the order of malignancy, the small round-celled variety stands first, 
while fibrosarcoma appears in many instances to be relatively benign. 
Eothrock has observed a case of spindle-celled sarcoma involving 
both ovaries, in which the patient died of metastasis to the perito- 
neum six months after operation for their removal. 

Metastasis to other organs of 
the body occurs, acording to Te- 
mesvary, in the following order of 
frequency: peritoneum, omentum, 
stomach, pleura, lungs, uterus, liv- 
er, diaphragm, kidney. Sarcoma of 
the ovary frequently undergoes de- 
generative changes, the most com- 
mon of which, are myxomatous and 
fatty degenerations. 

Endothelioma of the Ovary. — 
Occupying an intermediate place 
between carcinoma and sarcoma, 
there is a group of malignant tu- 
mours of the ovary possessing 
many of the clinical features of 
both, but differing from them in 
anatomic structure. 

Leopold, first, in 1874, de- 
scribed a case under the name of lymphangeioma cystomatosum. Tu- 
mours of similar structure had, previously to this, been frequently ob- 
served occurring in other regions of the body, and were called angio- 
sarcoma and lymphangeiosarcoma. 

Marchand, in 1879, was the first to give a detailed description of 
these tumours and to distinguish them from both carcinoma and sar- 
coma, in spite of the great similarity in many respects to the struc- 
ture of both. He named them endothelioma, thus denoting their 
origin from the endothelium of the blood or lymph vessels. Since 
then, tumours of the same kind have been described by different au- 
thors, so that we may now form some conclusions concerning the most 
important features of these growths. 

Endothelioma of the ovary is, in most instances, a solid tumour 
(Fig. 272). It has been met with most frequently in middle age or 
beyond it, though Leopold has observed it in an eight-year-old girl, and 
Olshausen in a girl seventeen years of age. 

These tumours vary in size from that of a closed fist to that of a 
man's head, and are usually unilateral, though bilateral tumours have 
been observed. In shape, they are commonly rounded, or they may 
be multinodular or lobulated. The surface of the tumour may be 
smooth or rough, and its consistence firm or soft. Usually the 
tumour is attached by a short pedicle, and it frequently forms adhe- 
sions to the surrounding structures. 



NEOPLASMS OF THE OVARIES 



625 




Fig. 272. — " Endothelioma of the ovary is in 
most instances a solid tumour." — Eoth- 
kock (page 624). 



On section, the cut surface is of a yellow, gray, or white colour, 
often brainlike in appearance and consistence, and easily torn by the 
finger. Frequently, it is made up largely of fibrous structure in which 
are present nodular areas of softer 
consistence. Again the tumour 
may be composed of numerous 
small cysts in a rather dense 
stroma, thus giving it a honey- 
combed or worm-eaten appear- 
ance (Pick). In other instances, 
the tumour appears cavernous, 
or may be laminated in struc- 
ture. Cyst formation occurs 
chiefly in the lymphatic variety. 
Barely, papillary formations have 
been observed within the cyst, the 
histologic structure of which is 
fibrous. These tumours have their 

origin in the endothelium of the blood and lymph vessels, and, histo- 
logically, they present the greatest variety of structure (Fig. 273). 
Pick has distinguished three types: 

(1) A rosarylike form, consisting of chains of cells arranged in 
rows, lying in narrow spaces or clefts in the stroma; their borders 

run parallel, and they 
frequently anastomose 
with each other or send 
off branches. 

(2) The second con- 
sists of glandlike forma- 
tions which, on trans- 
verse section, furnish a 
picture often difficult to 
distinguish from adeno- 
carcinoma, as the lumen 
of these glandlike spaces 
is often encroached 
upon hy several lay- 
ers of polymorphous 
cells. 

(3) The third form 
consists of a histologic 
formation resembling 
alveolar sarcoma, and 
appears as groups of 

rounded epithelioid cell bodies filling alveolalike spaces in the rather 
dense fibrous stroma. Not infrequently, all three types may be found 
in the same tumour. 
41 




Fig. 273 (Whitacre). — " Histologically they present th< 
greatest variety of structure." — Eothrock. 



626 A TEXT-BOOK OF GYNECOLOGY 

Endothelioma is frequently found in combination with other 
tumours of the ovary. The cases of Eckhard, Flaischlen, and Po- 
morski, were cystic, and contained dermoid structures, while Pfannen- 
stiel has observed a combination of endothelioma with true epithelial 
cystadenoma. They are very prone to undergo degenerative changes,, 
the most common being hyaline and myxomatous degeneration, while 
colloid and fatty degeneration have also been observed. 

Clinically, they are malignant. In a case of Leopold's, which was 
unsuited to operation, the patient died of cachexia within six months. 

As regards recurrence following operation, there are only scanty 
data available upon which to base an opinion. Of 7 cases tabulated by 
von Velits, only 2 recovered from the operation. In 2 cases, metastasis 
was observed, while 4 had pronounced cachexia. Billroth regarded 
these tumours as in the same order of malignancy as carcinoma. 



CHAPTEE XLI 

NEOPLASMS OF THE OVARIES (Continued) 

Complications — Symptomatology — Diagnosis — Treatment — Ovariotomy : History, 
technique, results — Incomplete ovariotomy — Ovariotomy during pregnancy. 

The complications of ovarian tumours are various as there is no rea- 
son why an ovarian tumour should not develop in the presence of any 
other visceral lesion. These growths occur, therefore, coincidently 
with neoplasms of the uterus, cysts of the mesentery, nephrydrosis, 
hypertrophies of the spleen, enormous distentions of the gall bladder, 
cysts of the urachus, etc. Among the more important complications, 
however, are (a) pregnancy, (&) torsion of the pedicle, (c) ascites, 
(d) albuminuria, (e) adhesions, (/) rupture of the tumour. 

Pregnancy as a complication of ovarian tumour is not an infre- 
quent occurrence in practice. Sir Spencer Wells, after an experience in 
ovariotomy greater than any which had then fallen to the lot of any 
other man, observed that, " certainly the most common mistakes in 
the diagnosis occur when the tumour is enlarged from some cause, and 
pregnancy is the most common of all causes of enlargement of the 
uterus. When a patient has no reason for deceiving her adviser, doubt 
or difficulty will often arise; and in cases of pregnancy, real or sus- 
pected, the patient may mislead the surgeon intentionally, or from 
her own hopes or fears biasing her judgment." This complication is 
always a condition of serious import. Pregnancy is liable to give a 
fresh impetus to the growth of a tumour, while the tumour, in turn, 
may exercise a deleterious influence upon the gravid uterus. Abortion 
is not an infrequent sequence. If the case goes to term, rupture of a 
thin-walled cyst is liable to occur as the result of the muscular con- 
traction of the abdominal wall. Inflammation resulting in adhesions 
between the cyst and either the intestines or abdominal wall, or both, 
may be induced. Twisting of the pedicle may occur as the result of 
the changed position of the cyst following the collapse of the parturient 
uterus. Gottschalk (Frauenarzt) has reported a case of infection of 
the cyst by the colon bacillus, and Zetter has reported 21 cases of cyst 
infection occurring during the puerperium. 

The mortality, both maternal and foetal, is very high in these cases 
when left to themselves. Heiberg found that 25 per cent of mothers, 
and 75 per cent of children, died in 271 cases in which pregnancy, 
coexisting with ovarian tumour, was permitted to go to term. Zetter 

627 



628 A TEXT-BOOK OF GYNECOLOGY 

gives the maternal death-rate at about 30 per cent, while Litzmann 
places it at 43 per cent. 

Torsion of the pedicle, as the result of axial rotation of the tumour, 
occurs with sufficient frequency, and is a complication of such gravity, 
as to entitle it to consideration in this connection. Knowsley Thorn- 
ton found a twisted pedicle 57 times in 600 cases of ovariotomy. It 
is a complication to which Kokitansky first called attention in 1865. 
He described 13 cases, 8 of them having been encountered in post- 
mortem examinations made in 58 cases of ovarian disease. Sir Spencer 
Wells, Kolb, Peaslee, and Barnes, were among the early observers of 
this complication. 

The causes of axial rotation of ovarian tumours have been the sub- 
ject of repeated speculation. Tait advanced the theory that descending 
masses of faecal matter caused the tumour to turn. Doran believes 
{Tumours of the Ovary) that the twisting of a pedicle is to be explained 
by the simpler doctrine that the tumour, pressed upon by the viscera, 
and even by the costal cartilages above and the pelvic structures below, 
but comparatively free laterally and anteriorly, rotates on its own 
axis every time the patient after walking or lying on her back turns 
round and rests on her side. Accidents, direct violence, sudden strain, 
and sudden change of position, were the determining causes of the 
attack in 8 of Thornton's cases. Pregnancy seems to bear a causal rela- 
tion to the complication. The pathologic changes are dependent upon 
the mechanical obstruction to the efferent circulation. The compara- 
tively firm and relatively noncompressible arteries continue to pump 
blood into the tumour, while the obstructed veins can not carry it out. 
As a result, there is an enormous increase in the volume of the growth, 
accompanied by acute pain which is referred chiefly to the pedicle, a 
fact which Thornton considers due to the pressure to which the nerves 
are subjected at that point. In extreme cases, the pain extends over 
the entire area of the tumour. Coincidently with this turgescence of 
the tissues, there occurs a transudation of sanguiferous elements upon 
the surface of the tumour. In some cases, the blood vessels rupture 
either into the peritoneal cavity or into the cavity of the tumour. 
Secondary rupture of the hemorrhagic tumour, the blood and pseudo- 
mucinous contents escaping into the peritoneum, has been noted. 
The incised wall of a tumour the pedicle of which has been twisted, 
reveals numerous hemorrhages, varying from punctate clots to large 
hematomata. While, as a rule, these tumours perish by the necrosis 
induced by strangulation, there are exceptional instances in which 
they have survived by virtue of nutrition derived from the newly 
formed peripheral adhesions. These are a distinct feature of the patho- 
logic changes observed in the majority of cases. Eeed has had a case 
in which there was a distinct history of rotation of the tumour, but 
in which operation was denied because the patient was in extremis. 
After several days her symptoms began to improve, and six months later 
she was in good health with a tumour of diminished volume. 



NEOPLASMS OF THE OVARIES 629 

The symptoms of twisted pedicle are, sudden pain in the ovarian 
region, which may extend rapidly over the area of the tumour, and 
rapid increase in volume of the tumour, the patient manifesting signs 
of shock, associated sooner or later with evidences of systemic toxaemia. 
Vomiting may or may not be present. The diagnosis is not difficult if 
an ovarian tumour is known to exist. There is frequent extensive 
peritoneal tenderness. The treatment of this condition is by immediate 
ovariotomy. 

The changes observable in a cyst with a twisted pedicle are, first, 
oedema of the cyst wall, and, next, distention of the sac. Serous exu- 
dation from the circulation, following in the direction of least resist- 
ance, takes place as a rule into the cyst cavity rather than upon its 
surface. A certain amount of transudation is, however, observable on 
the surface, a condition which favours the speedy development of ad- 
hesions. The blood pressure becomes so great that hemorrhages fre- 
quently occur, as a rule into the cavity of the cyst, but occasionally 
upon the surface. It is rare that the cystic fluid in these cases is not 
discoloured by blood elements. The blood pressure may become so 
great as to induce cell necrosis. 

The treatment of twisted pedicle is incontestably by operation; " the 
only question admitting of discussion," says Eichardson (Virginia 
Medical Semimonthly), " is that of the most advantageous time. The 
conditions in one case demanding operation, in another justifying it, 
are not unlike those seen in appendicitis and in extrauterine preg- 
nancy. Under some circumstances intervention should be delayed for 
a more favourable moment; under others it can not be too prompt. 

" It can not be too prompt when the lesion is recognised before 
shock has become profound, and before sepsis has become pronounced. 
Nor can it be too early when the symptoms are increasing, even if 
shock and sepsis are grave enough seriously to compromise the imme- 
diate success of intervention. When, however, the patient is improv- 
ing, when the immediate effects of hemorrhage, of sepsis, or of both, 
are being recovered from, then the wisdom of intervention must be 
questioned. The patient must be carefully watched and a time awaited 
when she can safely withstand the added shock of operation. In the 
lesion under consideration the pulse is the most valuable guide. What- 
ever the other signs may be, whether the temperature be high or low, 
whether there be tenderness or not, whether there be distention, rigid- 
ity, vomiting, obstipation — in a word, whether there be general peri- 
tonitis or not, the tumour should be removed immediately if the 
pulse is good. More than this, it must be removed if it is getting worse. 
On the other hand, a pulse that from being bad is rapidly improving, 
justifies a short delay, even if other signs are bad. When all signs, 
from being grave, are improving, a reasonable delay is but common 
sense. To wait for improvement when there is no sign of improvement 
seems to me unjustifiable; for too often, especially in hemorrhage, 
there will be no improvement. The risk of intervention must be taken. 



630 A TEXT-BOOK OF GYNECOLOGY 

When bleeding is suspected, and when the pulse is poor or impercep- 
tible, intravenous injections of salt solution should be made, and the 
utmost speed of enucleation used. In the profound shock of general 
peritoneal infection without hemorrhage, salt solutions may also be 
used, but here one must not be disappointed by failure. In hemor- 
rhage, an infusion of salt solution into the veins adds the circulating 
medium needed by the nagging heart; in sepsis it simply dilutes an 
abundant supply of vitiated blood — in the one case it tides the patient 
successfully over a grave crisis; in the other it merely postpones the 
fatal event. 

" Whether delay be practised or not, every effort should be made to 
add to the patient's strength. In addition to intravenous injections, 
stimulating enemata of hot salt solution and brandy and coffee should 
be given. If not vomiting, the patient should be given stimulants by 
mouth. Hypodermic injections of strychnine, brandy, ether, and 
other cardiac stimulants may be given. The whole body should be 
kept warm by means of hot-water bottles and hot blankets, and the 
foot of the bed should be elevated. While the strength is being re- 
stored in this manner, preparations for operation should be made. 
It is important, especially if free blood is in the abdominal cavity, that 
the operation be extremely aseptic, because infection is so apt to take 
place after hasty preparations of the operative field. Yet in advancing 
shock and hemorrhage it may not be possible to sterilize thoroughly 
the field, lest the patient die before the operation can be begun. The 
risk of infection from hasty and incomplete preparation must there- 
fore be taken. 

" It must not be inferred, however, that so hasty an intervention 
is always demanded. In all but one of the cases here reported the 
operation was performed after due consideration; the patient recovered 
fully from the initial shock, and was operated upon some time later. 
In but one was immediate operation performed, and in that case there 
was already a fatal gangrene. Hemorrhage was an important factor in 
but one instance." 

Ascites is sometimes caused by an ovarian tumour with which it 
may then coexist as a complication. It is to be remembered, however, 
that in many of these cases, the intraperitoneal accumulation of fluid 
may be the result of cardiac, renal, or hepatic disease. Care should 
be exercised to ascertain as nearly as possible the exact condition of 
these organs, and their possible causal relation to the ascites. If any 
of them present diseased conditions they should be subjected to appro- 
priate treatment. It is true that this treatment may sometimes need 
to begin with ovariotomy, for renal, hepatic, and intestinal complica- 
tions may be caused in the first instance, either by direct pressure from 
a large ovarian tumour, or by the mechanical interference of that 
tumour with the portal circulation. As a rule, however, such condi- 
tions may be found amenable to treatment before ovariotomy is per- 
formed, and when this can be accomplished it should be done. Douglas 



♦ NEOPLASMS OF THE OVARIES 631 

says that a small tumour, with ascites appearing early, is strongly pre- 
sumptive of malignancy. If the ascites is from obstructed circulation, 
the liquid will be a limpid fluid resembling water, perhaps slightly 
coloured, containing a little albumin but no fibrin, and giving no 
sediment. If the ascites is from peritoneal inflammation, the liquid 
will be thinner but never transparent, always cloudy, looking like but- 
termilk, and smelling like decayed cheese. If the effusion is from 
simple serous irritation, the liquid will be albuminous, rather clear, 
though sometimes coloured like bile. In the sediment will be found ele- 
ments of great importance. Large irregular cells may be seen, having 
a central nucleus surrounded by a quantity of granulations. The 
presence of these cells is usually taken as a sign of malignant growth. 

Albuminuria is of frequent occurrence in connection with the 
larger cysts of the ovary. "When the growth attains such a size that 
it exerts pressure upon the kidneys, albumin is almost sure to appear 
in the urine, the condition being practically analogous to that which 
is frequently found in pregnancy. If the disease has been of long 
standing, the changes thereby induced in the kidney may have reached 
the destructive degree. It is highly important, as a matter of routine, 
that the urine be investigated in all these cases before operation. The 
facts thereby elicited will have an important bearing upon the selec- 
tion of an anaesthetic and upon the prognosis of the case. 

Adhesions are liable to occur as the result of mechanical hyperemia, 
traumatism, or infection of the tumour. Adhesions may be single or 
multiple, firm or friable, local or general, and may bind the tumour 
to either the visceral or the parietal peritoneum. Adhesions between 
the tumour and the intestines, the abdominal wall, or the omentum, 
are naturally the more frequent. While it is true that peritonitis ordi- 
narily results in the formation of adhesions, yet, Douglas and others 
have reported cases in which such a result did not follow distinct in- 
flammatory attacks. Persistent, definitely localized pain, of the trac- 
tion variety, at some point of the surface of the tumour is suggestive 
of adhesion, but the condition can not be said to present a definite 
symptomatology. 

Bupture of the tumour, when cystic, may be induced by overdis- 
tention, papillomatous degeneration, infection, or violence. It fre- 
quently happens that, in cysts of the pseudomucinous variety, the 
secondary peripheral growths have veiy thin walls, and are, conse- 
quently, more liable to rupture from any of the preceding causes. The 
larger sacs, however, have been known to empty their entire contents 
into the peritoneal cavity. This is an accident which may or may not 
produce profound symptoms. If the rupture is slight, the sac small, and 
the fluid bland, the accident may be almost symptomless; whereas, if the 
rupture is extensive, the sac voluminous, and the fluid irritating or 
septic, the symptoms may be those of profound shock, followed by acute 
peritonitis and septicaemia. There is no means of determining in ad- 
vance of exploration the exact character of the fluid of any ovarian 



632 A TEXT-BOOK OF GYNECOLOGY 

tumour. Pure pseudomucin is not irritating, nor is it septic, but if 
the tumour has become the seat of infection, however slight, this ma- 
terial serves as a convenient culture medium, and may thus become the 
source of contamination. When there are grounds for suspecting rup- 
ture of the sac, the indication is for immediate operation by abdominal 
section. 

The symptomatology of ovarian neoplasms is sometimes very ob- 
scure. In certain forms of ovarian growth, notably in dermoids, there 
is pain from a very early period. In a majority of cases, however, there 
is nothing more than a vague sense of discomfort in the pelvis, due 
to the weight and tension exercised by the developing tumour. In 
many cases, there are no symptoms whatever to attract attention to 
the pelvis until the patient by accident discovers that she has an en- 
largement in either one or the other lower quadrant of the abdomen. 
There may or may not be disturbance of the menstruation, and, even 
in ovarian tumours of large development, the menstrual function seems 
to be but slightly modified. This modification of function may tend 
in the direction of either increase or diminution of the flow. In those 
cases in which the flow has increased, there will generally be found 
an antecedent history of pelvic disturbance — probably of an endo- 
metritis. In cases of amenorrhcea due to developing ovarian cystoma,, 
the disappearance of menstruation, coincidently with abdominal dis- 
tention, may lead to a suspicion of pregnancy. Cases of this kind are 
of frequent occurrence. While the tumour is yet relatively small, it 
occupies a position within the true pelvis, but as it grows larger it 
ascends into the abdominal cavity just as does a pregnant uterus. 
When the tumour is yet within the pelvis, its weight generally causes, 
it to fall into the cul-de-sac of Douglas, usually either to one side 
or the other of the uterus. At this stage of its development, bimanual 
examination will enable the surgeon to outline the growth, and per- 
haps to determine from which side it develops. It is generally felt 
as a hard, or semi-fluctuating globular mass, its spherical outline being 
readily detected by palpation through the abdominal wall. To deter- 
mine the side from which it develops and the location of its pedicle, 
Hegar advises drawing down the uterus with a tenaculum, employing 
the rectal touch or bimanual manipulation to outline the attachment. 
The mobility of the tumour depends upon the length and size of its 
pedicle, which is sometimes long enough to permit the growth to be 
carried far up to the pelvic brim, while in other cases it is so short 
that the tumour feels more like an abscess than a neoplasm. In some 
cases, the tumours are bilateral, a circumstance which may readily be 
confused with a multilocular or a multinodular growth. The uterus 
is very liable to be displaced to either one side or the other — or, as 
occasionally happens, the growth may be poised above and behind the 
womb, forcing the latter forward into a state of extreme ante version. 
As the tumour grows larger, however, and descends into the abdominal 
cavity, its spherical outline becomes more and more apparent by 



NEOPLASMS OP THE OVARIES 633 

abdominal palpation. Irregular bosses or protuberances upon the 
surface of the growth indicate that it is multilocular. On percussion, 
the tumour will yield dulness over its entire area. One of the essential 
diagnostic signs relied upon by Dunlap, who was one of the very earliest 
of the world's ovariotomists, was the position of the intestines. As the 
tumour develops from one side or the other of the pelvis, the bowels 
are pushed upward and toward the opposite side. Abdominal reso- 
nance is restricted to the area occupied by the intestines. This position 
should be more or less constant. If a patient with fluctuating disten- 
tion of the abdomen yields an area of dulness in the lower two quad- 
rants of the abdomen, with a resonant note above, and if she mani- 
fests these signs both when sitting and lying, it may be safely assumed 
that she is either pregnant or is the victim of an ovarian tumour. If, 
however, upon lying down, the area of resonance descends toward 
the pubes, a suspicion of ascites, rather than of either of the fore- 
going, is justifiable. As the cyst increases in size and weight, it exer- 
cises increasing pressure upon the neighbouring viscera; this is the 
frequent cause of vesical irritation, constipation, and occasional pro- 
found disturbance of the kidneys. The urine, under such circum- 
stances, becomes scanty, is loaded with albumin, and, if the pressure 
is long sustained, oedema of the extremity is the result. Hemorrhoids 
are another annoying result of pressure. Areas of pelvic tenderness 
are sometimes complained of when the tumour has attained consider- 
able size. These are generally the results of either pressure or slight 
traumatisms, and depend upon the fact that the tumour, after attaining 
considerable size, may lose areas of protective epithelium and form 
adhesions to either the visceral or the parietal peritoneum. 

The diagnosis of ovarian neoplasms is of importance, not only to 
establish their existence and whether they are ovarian in origin, 
but also to determine whether or not they are malignant. The effort 
to distinguish with accuracy between the different varieties of benign 
neoplasms is to be looked upon, from the practical standpoint, largely 
as a useless expenditure of energy and a waste of valuable time. It 
may be stated as a rule to which there are no exceptions, that ovarian 
growths, either by virtue of their primary characteristics, or in con- 
sequence of secondary changes, tend to the death of the patient. 
It follows from this fact that all ovarian growths should be sub- 
jected sooner or later to extirpation. The tendency to malignant 
degeneration, already noted, renders it important that even the so- 
called benign growths should be removed without unnecessary de- 
lay. This being true, it is not necessary to subject the patient to 
punchings, pommelings, and punctures, to establish the exact vari- 
ety of the growth; for, after it has all been done, and the guessing 
is all over, precisely the same thing remains to be done. It is, how- 
ever, frequently important for various reasons personal to the patient 
to indulge in delay; and it is, therefore, important to know with 
approximate accuracy, whether a given tumour is malignant or 



634 A TEXT-BOOK OF GYNECOLOGY 

benign. This fact, unfortunately, is not one that can be easily deter- 
mined. It may be accepted as a rule, however, that the more rapid the 
growth, the more liable is it to be of a malignant character. The 
solid tumours are of the slowest growth, while proliferating cysts grow 
with more rapidity than any other of the benign neoplasms. When a 
growth which has been increasing at a certain rate manifests sudden 
acceleration in development, it should become an object of suspicion; 
the sudden increase may depend upon a change of type from benign 
to malignant, or, it may mean that the efferent circulation of the 
tumour has been interfered with, either by pressure of the growth 
itself, by torsion of the pedicle, or by other causes. The increase in 
the volume of a tumour due to sudden twisting of the pedicle is very 
sudden, and is associated with pain, followed in the course of a few 
days by toxaemic symptoms due to the absorption of necrotic products 
from the tumour itself. Increase of size due to a twisted pedicle may 
become spontaneously arrested, the tumour itself surviving by virtue of 
nutrition derived from extensive peripheral adhesions. 

The diagnosis of small ovarian tumours is relatively difficult, 
although Davenport (Boston Medical and Surgical Journal) insists that 
they are usually accompanied by well-marked symptoms. He states, 
however, that pain, while usually present, does not bear any constant 
relation in its location, to either the situation or the variety of the 
tumour. Menstrual disturbances are the rule, the variation tending in 
the direction of excessive rather than of diminished flow. There seems 
to be a direct causal connection between severe uterine hemorrhages and 
cystic ovaries when the latter are closely adherent to the uterus. 
Uterine hemorrhage, associated with a pelvic tumour which is unin- 
fluenced by intrauterine treatment, is more likely to be due to an 
ovarian tumour than to a fibroid. Keflex symptoms are comparatively 
rare, and, according to Davenport, occur chiefly in the later stages of 
the disease. 

The diagnosis of even large cystomata of the ovary is not always 
easy. A number of the most distinguished operators have mistaken 
pregnancy for an ovarian cyst. It may be stated that there are but few 
distinguished operators in the world who have not at one time or 
another made an exploratory incision, with the result of finding a 
pregnant uterus instead of the suspected cyst. (See Pregnancy as a 
Complication of Ovarian Tumours.) In extenuation of this accident, 
it should be remembered that an ovarian tumour may occupy such a 
position as to interfere with the detection of pregnancy by either 
vaginal or bimanual manipulation, and it must be remembered, further- 
more, that among the occasional erratic symptoms of ovarian cystoma, 
are reflex vomiting and mammary development, with enlargement, 
softening, and blue coloration, of the cervix. In view of these facts, 
occasional mistakes are to be expected. In the great majority of in- 
stances of pregnancy, however, the placental bruit may be heard, while, 
later, ballottement may be practised; and, after the period of quicken- 



KEOPLASMS OF THE OVARIES 635 

ing, the foetal heart may generally be detected. It must be remembered, 
however, that even these signs may be obscured. This is particularly 
true of the placental bruit, which may be completely masked by the 
more pronounced bruit of the almost cavernous veins that develop in 
certain of these tumours. Ballottement may be defeated by the ascent 
of the uterus and the relatively low position of the tumour; while the 
foetal heart may be situated so remotely that its pulsations can not be 
heard. Ascites is not infrequently mistaken for a unilocular ovarian 
cyst. This is particularly true in cases of encysted ascites, where the 
induced area of dulness remains inconstant, even when the patient 
assumes different positions. The ascites of tuberculous peritonitis 
frequently occurs in connection with tuberculous involvement of the 
mesenteries, or, at least, of the meso-enteron. The result of tuber- 
culous infection in this locality is a contraction of the peritoneal fold, 
which prevents the intestines, even when laden with gas, from floating 
upon the surface of the ascitic fluid. In these cases, however, the 
morphology of the growth may be taken as a reasonably safe index of 
its character. A tumour fluctuating and spherical in the upright pos- 
ture will maintain its outlines with but trifling variation when the 
patient lies down, whereas, if the distention depends upon free fluid in 
the peritoneal cavity, the abdomen will flatten to a certain degree, while 
there will be a corresponding distention of the ilio-costal interval. It 
rarely happens that a tumour so develops as to distend the abdominal 
wall between the crest of the ilium and the ribs. 

Large cysts of the mesentery and neplirydrosis have been mistaken for 
ovarian cysts. To distinguish between an ovarian cyst and neplirydrosis 
it is important to remember that, in the former, the tumour develops 
from below upward, and in the latter from above downward. In the 
former, the upper, and in the latter, the lower margin of the growth 
is free. This sign is, of course, absent when the cyst is large enough 
to fill the abdominal cavity. If the tumour is of congenital origin, the 
presumption of neplirydrosis is strengthened, although Alban Doran 
has reported a case of congenital ovarian tumour. The position of 
the colon relatively to the cysts is important in distinguishing between 
these two conditions. In many cases, the bowel can not be palpated or 
percussed; under which circumstances Simon introduced an effervescing 
enema to distend the bowel. Exploratory puncture has been practised 
as a diagnostic means in cases of suspected neplirydrosis, but it is not to 
be recommended, not only for the reasons already enumerated, but 
because, according to Pozzi, the fluid from neplirydrosis is no more 
characteristic than is that from the proliferating serous cyst of the 
ovary or of the parovarium. Urea and uric acid may be absent from 
neplirydrosis and present in an ovarian cyst, a circumstance which will 
only tend to increase the pre-existing confusion. Urethral catheteriza- 
tion, as practised by Pawlick and Kelly, may be of value in distinguish- 
ing between these two frequently confusing conditions. 

Ecliinococcoas cysts of the peritoneal cavity may be mistaken for 



636 A TEXT-BOOK OF GYNECOLOGY 

ovarian tumours. They acquire great volume and give rise to corre- 
sponding distention of the abdominal walls. They may displace vis- 
cera, encroach upon the diaphragm, and occasion interference with 
the action of the heart and lungs, just as occurs in cases of advanced 
or neglected ovarian tumours. The facts, however, that the growth 
started in one of the upper quadrants of the abdomen, generally the 
right, extending thence toward the pelvis, and that the growth is more 
rapid than is ordinarily the case in pelvic tumours, will place the 
practitioner upon his guard. The fluctuation in hydatids is remote 
and circumscribed. The hydatid fremitus is considered characteristic 
and decisive. It is presumed that, in the majority of these cases, 
the origin of the parasitic infection is in the liver, and that the con- 
tamination of the peritoneum is consecutive to rupture of a lymphatic 
cyst and the consequent escape of the echinococci into the peritoneal 
cavity. When once implanted in the peritoneum, however, these para- 
sites may go on multiplying in any one cavity. They may undergo 
retrogressive changes and may, themselves, become the seat of bacterial 
infection. Sir Spencer Wells has recorded a case in which the degenera- 
tion of the hydatid cysts was associated with the formation of gas, due, 
in all probability, to the action of the Bacillus aerogenes capsulatus. 

Large malignant neoplasms of the lymphatics may occasion confu- 
sion in making a diagnosis of a seeming ovarian tumour. These 
growths may originate from the lymphatic glands within the broad 
ligament, or beneath the pelvic peritoneum, or even higher up. Dr. 
Mary Almira Smith, of Boston, has reported an interesting case in 
which a large malignant growth had developed from a lumbar lym- 
phatic gland. It was the size of a child's head and presented all the 
physical characteristics of an ovarian tumour. 

Phantom tumour yields a resonant note on percussion and entirely 
disappears under anaesthesia. 

A distended Madder has been mistaken by very capable physicians 
for an ovarian cyst. When the fluctuating tumour occupies a median 
position and extends to the symphysis pubis, and when it can not be 
moved from this position, a catheter should always be inserted as a 
precautionary measure. The indication for catheterization is positive 
when the patient complains of slight incontinence. 

Fihrocy stoma of the uterus may present many physical signs in com- 
mon with an ovarian tumour. Eishmiller, in this connection, calls 
attention to the fact that fibrocystoma of the uterus is relatively 
infrequent and occurs usually in women over thirty years of age.' 
Its growth is slow at first, but rapid after attaining a certain size. 
Menorrhagia is seldom present. In fibrocystoma we have a lobulated 
condition which can be felt through the abdominal parietes, umbilicus 
not prominent, uterus moving with the tumour and the uterine cavity 
generally elongated; while, in ovarian cyst, we have no lobulation 
except in polycysts, the umbilicus is prominent, the uterus moves 
independently of the tumour and its cavity is not elongated. The de- 



NEOPLASMS OF THE OVARIES 637 

tection of hard nodules would be significant, but hard and tense cysts 
may impart the same sensation. Fluctuation is very hard to detect 
for the reason that the tumour gives rather an elastic feel. 

These confusing conditions occurring with relative frequency in 
the hands of the most distinguished and experienced operators, be- 
came so apparent to Lawson Tait that he proclaimed, not only the 
expediency, but the importance of exploratory incision as a diagnostitial 
measure. This decree has been ratified by the universal acquiescence 
of the medical profession. The presence of an abdominal tumour of 
undetermined character and showing a constant tendency to increase 
in size, is of itself, not only a justification, but an imperative indica- 
tion for an exploratory abdominal section. The time has long since 
passed when surgeons felt justified in pronouncing an unequivocal 
diagnosis of the exact character of intra-abdominal growth upon 
evidence furnished by external examination alone. 

Puncture of the cyst through the abdominal wall, or through the 
vagina, is never a justifiable diagnostitial measure. The fact that 
puncture is sometimes practised without incident, does not in the 
least demonstrate that the operation is without danger, or that the 
operator is without responsibility. The possibility of wounding im- 
portant blood vessels, the location and development of which under 
these circumstances is always anomalous ; the possibility of punctur- 
ing a loop of intestine ; the probability of inducing a possibly septic 
seepage into the peritoneum; and the certainty of inducing adhe- 
sions, are all cogent reasons against a manoeuvre which, under the 
most favourable circumstances, can only be looked upon as groping in 
the dark. The demonstrated utility and innocuousness of explora- 
tory incision, undertaken with reference to the completion of the 
operation should it be found justifiable, renders preliminary puncture 
of the cyst neither necessary nor defensible. It is a matter of scientific 
interest, however, to know that a clear and noncoagulable fluid from 
an abdominal cyst probably indicates the parovarian origin of the 
latter, although proliferating serous cysts of true ovarian origin may 
yield a fluid of similar reaction; whereas, the demonstrated presence 
of pseudomucin (see Test for Pseudomucin) indicates that the cyst 
is of true ovarian origin. 

If it were true, which it is not, that the fluid obtained by tapping 
would enable the surgeon always to recognise the exact character of 
the cyst the manoeuvre would still be without practical value, because 
precisely the same treatment, namely ovariotomy, would be indicated, 
whether the fluid yielded pseudomucin or not. 

The treatment of neoplasms of the ovaries is necessarily surgical. 
All attempts to cure these growths or to arrest their progress and 
development by medicines, manipulations, or electricity, have proved, 
not only futile, but in many instances directly damaging to the pa- 
tient. It should be accepted as a rule, that all cases of ovarian 
tumours should be operated upon as soon after the diagnosis has 



638 A TEXT-BOOK OF GYNECOLOGY 

been made as the conditions will judiciously permit. Delay may be 
indulged in temporarily, to improve the general condition of the 
patient and to place her in a better condition for operation. But it 
should never be prolonged beyond the time necessary to put her in the 
best condition for ovariotomy. 

Ovariotomy. — History. — Ovariotomy was first performed by Dr. 
Ephraim McDowell, who lived in the town of Danville, in what was 
then known as the backwoods of Kentucky. He had been a student 
in Edinburgh of John Bell, who had suggested in his lectures both 
the possibility and the advisability of removing ovarian tumours, 
though he himself had never operated for this purpose. 

The seed sown in the mind of young McDowell brought forth its 
first fruit in 1809, when he removed a large ovarian tumour from Mrs. 
Marion Crawford, who not only recovered from the operation, but 
lived thirty-eight years afterward. Although McDowell did not pub- 
lish the report of this case and of two other similar operations until 
1816, his claim to be the first ovariotomist in the world is now every- 
where admitted without dispute. McDowell performed, altogether, 
13 ovariotomies, with 6 deaths. 

The principal operators in America to follow in the footsteps of 
McDowell within the next twenty-five years, were Dunlap, of Ohio, 
Nathan Smith, of Connecticut, Peaslee, of New York, and the Atlees 
of Pennsylvania. Lizars operated in Edinburgh in 1824 and 1825, 
but with such poor success that the operation did not gain much 
headway in Great Britain until 1842, when Charles Clay, of Man- 
chester, scored a success greater than any operator up to that date. 
Baker Brown, between 1852 and 1856, performed 9 ovariotomies with 
7 deaths. He operated no more for four years, when he began a most 
successful career which was suddenly cut off by his untimely death. 
In 1858, Spencer Wells, of London, commenced his remarkable record, 
which, at the time of his death, had gone well up toward 2,000 cases. 
He reduced the mortality of this operation to 25 per cent but never 
got much below that figure. In 1862 Thomas Keith, of Edinburgh, 
performed his first operation and soon became the most successful 
living ovariotomist. Lawson Tait, of Birmingham, in the course of his 
extraordinary and startling career reported a series of 139 ovariot- 
omies without a death. Bantock and Thornton, of London, following 
in the footsteps of Spencer Wells, in the Samaritan Free Hospital 
of that city, greatly improved upon the teachings of their master, 
and reported long series of ovariotomies with much smaller mor- 
tality than Wells had ever been able to secure. In France the opera- 
tion did not make equally rapid headway until Pean and his followers 
began to do very successful work. On the Continent, Koeberle, 
Schroder, Billroth, Martin, Leopold, Sanger, and many others, began 
and carried on the good work, until now, in all parts of the world, 
ovariotomy is one of the most successful of modern surgical opera- 
tions. Thousands of women have had their lives saved, and have lived 



NEOPLASMS OF THE OVARIES 



639 



long years of usefulness and happiness as a final result of McDowell's 
glorious effort in 1809. 

Indications. — Ovarian tumours should be removed as soon as prep- 
aration can be conveniently made after their diagnosis. There is no 
wisdom whatever in delay. Nothing can be gained and everything 
may be lost by putting off the operation. No medicine, or outward 
application or treatment of any kind whatsoever, is likely to cure an 
ovarian tumour. As ovariotomy is the only source of relief, the 
sooner it is resorted to the better. The life of a woman with an ova- 
rian tumour, as a rule, is not greater than three years from the time 
of its discovery. She is likely never to be in a better condition for 
the operation than at the time of diagnosis. The chief indication 
then for ovariotomy is a clear and unmistakable diagnosis. 

Technique. — While a full description of the technique of ovarioto- 
my would require a statement in regard to the preparation of the 
patient, of the operating room, of the surgeon, his assistants and 
nurses, the instruments, sponges and dressings, etc., the limited space 
allotted to this chapter will not permit of these otherwise necessary 
details, especially as the general subject of operative technique is fully 
described in another part of this work. Eeaders are referred, there- 
fore, to the chapter on general technique for a descrip- 
tion of the arrangement of the sterilized instruments 
and towels, and of the nurses with their sponges and 
their basins of hot and cold water, their sterilized solu- 
tions, etc., while we proceed at once with a description 
of the technique of the " operation itself," which, for 
the sake of convenience and brevity, may be described 
under the following heads: 

1. Instruments required. 

2. The anaesthetic and the angesthetizer. 

3. The incision of the abdominal wall. 

4. Tapping and removing the contents of the cyst. 

5. The treatment of adhesions and the ligation of the 
pedicle. 

6. The toilet of the peritoneum. 

7. Irrigation and drainage. 

8. Accidents and complications. 

9. Closure of the wound. 

10. Dressings. 

11. After-treatment. 

Instruments. — The instruments necessary for an un- 
complicated ovariotomy might readily be carried in the 
surgeon's overcoat pocket, but as we so often come upon 
the unexpected in the abdominal cavity, an experienced 
ovariotomist will have sterilized at the same time everything which 
he might require in case he should meet with complications and con- 
ditions which he had not suspected when he made his diagnosis. 



Fig. 274.— Dis- 
secting forceps 
(page 640). 



640 



A TEXT-BOOK OF GYNECOLOGY 



The instruments most frequently required are: one or two sharp 
scalpels; a dozen hemostatic forceps; half a dozen prepared sponges or 
gauze pads; three pairs of scissors, one long and straight, one curved 
on the flat and blunt pointed, and one short, thick, strong, and curved 



u^ 




Fig. 275. — Curved trocar, 



at right angles; two dissecting forceps (Fig. 274) for picking up the 
peritoneum; Tait's or Spencer Wells's trocar with long rubber tubing 
attached, to conduct the fluid into a bucket under the table (Fig. 275); 
two large cyst forceps, to grasp and withdraw the empty sac; two long 
aneurism needles, threaded at the point, for 
transfixing and ligating the pedicle; a good, 
free-working irrigation apparatus; needles long, 
straight, and curved, to close the abdominal in- 
cision; an assortment of sterilized silk, silkworm 
gut, and catgut; long perforated glass tubes and 
sterilized gauze, to be used, if necessary, in 
drainage. 

. The following, also, may be needed: An as- 
sortment of large and small pressure forceps 
(Fig. 276), a catheter, retractors, rubber cord or 
tubing, fine curved and straight needles, a port- 
able electric light, an electro-cautery, and Mon- 
sel's solution. All these instruments, sutures, 
etc., should be carefully assorted and placed in 
appropriate trays upon a table near by, and cov- 
ered with sterilized hot water by the assistant 
who is to hand them to the operator as needed, 
during the various stages of the operation. A 
basin of hot water should be placed upon a small 
table near the surgeon in which he can immedi- 
ately cleanse his hands should they become soiled 
with pus or fluid from the tumour. This water 
will need to be frequently changed as the opera- 
tion proceeds. 

While these and all other preparations by the 
surgeon are going on, his assistants, and nurses, to insure an aseptic 
environment and operation, the patient, who has also been properly 
prepared, may be anaesthetized in an adjoining room, thus preventing 
the fright and shock of being brought into the operating room and 




Fig. 276.— Pressure 
forceps. 



NEOPLASMS OF THE OVARIES 641 

placed upon the table in plain sight of the instruments, the operator, 
and his assistants, in their operating costumes. 

The* A?icesthetic and the Ancesthetizer. — (See Anaesthesia.) 

The Abdominal Incision. — Although specially described elsewhere 
in this work, it may be well to say here that it need not be longer 
than 3 inches at first, and should be carefully and deliberately made. 
Reckless opening of the abdominal cavity with one stroke of the knife 
is as unwise as it is dangerous. Large unilocular ovarian tumours 
have been frequently removed by Joseph Taber Johnson and others 
through a 3-inch incision. Should occasion require, the opening can 
be easily enlarged with the scissors, when necessary, to deal with 
adhesions or to deliver partly solid tumours without bruising the 
tissues. 

While advocating the short incision, one as long as is necessary 
is always made as we proceed. It is not needful to spend valuable 
time in searching for the linea alba. Many surgeons think that a 
stronger cicatrix is secured by the union of the cut muscles. 

Before opening the peritoneum, all bleeding should be arrested. 
That membrane may now be caught up between two forceps and 
nicked with a knife or scissors. In order to avoid the possibility 
of injuring the intestines, it is safer to roll the peritoneum between 
the thumb and finger before opening it. The intestines, if not 
adherent, will immediately drop back out of harm's way as soon as 
air rushes in through the opening. The incision is now enlarged with 
the scissors upon the index finger, which acts at the same time as a 
guide and a protection to the intestines against injury (Fig. 35, p. 108). 
All bleeding having been arrested, two fingers of the left hand should 
be passed over the face of the tumour in all directions to ascertain the 
nature and extent of adhesions. 

The Emptying of the Cyst. — The pearly-gray cyst wall can be readily 
seen through the gaping edges of the wound, and a large-sized Tait or 
Wells trocar can be passed into the tumour at the upper angle of the 
wound and the fluid drawn off through a tube at the end of the trocar, 
which conducts it into a sanitary bucket underneath the table. The 
relapsing walls of the emptying cyst, unless prevented by adhesions, 
may now be drawn out of the wound with the fingers, or with large 
cyst forceps. The assistant should press together the abdominal walls, 
which will aid in the expulsion of the cyst contents and at the same 
time prevent the escape of intestines, the soiling of the edges of the 
abdominal wound by the fluid contents of the cyst, or their entering 
the abdominal cavity. If it should be a multilocular cyst, its various 
compartments may be emptied by passing the trocar in different direc- 
tions. If this does not succeed in reducing the size of the tumour 
sufficiently, the hand may be passed into an enlarged opening and these 
various compartments ruptured with the fingers. The hand, upon 
withdrawal, may bring the collapsed tumour sac along with it. It is 
wise to keep the opening in the cyst wall always outside the abdom- 
42 



642 A TEXT-BOOK OF GYNECOLOGY 

inal cavity in order to prevent the soiling and infection of the peri- 
toneum by any colloid, dermoid, or other infecting material which it 
would be exceedingly difficult to wash out. 

Adhesions of the Cyst and Ligation of the Pedicle. — Any adhesions 
which may exist will come into view as the empty sac is withdrawn. 
Those which are recent and the result of inflammation can be easily 
pressed off with a sponge, or separated with the fingers. Older and 
firmer adhesions, which are likely to contain blood vessels, should 
be ligated in two places with fine silk or catgut, and cut between the 
ligatures with the scissors. 

Adhesions of the omentum are generally vascular, and bleeding 
surfaces which are not controlled by exposure to the air or sponge 
pressure, may require ligation. When the cyst wall is adherent to 
the intestine, or can not be readily peeled off, a portion of it may be 
left attached, rather than to run the risk of laceration by its forced sepa- 
ration. Should an opening be made in the intestine, it should be 
immediately closed with fine silk. There are fewer incomplete opera- 
tions now than formerly. It is generally estimated that the mortality 
is greater where circumstances seem to require that the operation be 
left uncompleted, than where we are able to make a thorough re- 
moval of the tumour and toilet of the peritoneum, even in our worst 
cases. 

The ancient custom of Sir Spencer Wells, and many other distin- 
guished ovariotomists, in their day, of clamping the ovarian pedicle 
upon the outside of the abdomen is no longer practised. Clamps 
have been superseded by the ligature, the cautery, or the angeiotribe,, 
according to the preference of the operator. (See Hemostasis.) In 
each case, the constricted or seared stump is dropped back into the 
peritoneal cavity, and, in all cases where drainage is not required, the 
abdominal wound is completely closed. While an assistant holds up 
the empty sac or delivered tumour, the operator transfixes the pedicle 
as near as possible to the uterus with a long-handled, dull-pointed 
needle, threaded at the point with pure Chinese silk or catgut, 
according to his preference, and thus securely constricts the vessels 
and tissues in the pedicle. When doubt exists as to perfectly safe 
constriction, the ligature is brought around the entire mass and se- 
curely tied again, thus shutting off any possibility of subsequent hem- 
orrhage. A figure-of-eight or a Staffordshire knot, when properly 
applied is equally safe. Taber Johnson still retains his preference for 
pure Chinese silk ligatures for the pedicle. They very rarely become 
infected or make any trouble. Many more accidents have resulted 
from the relaxing, untying, or slipping off, of catgut ligatures, and 
from sepsis caused by imperfectly prepared catgut, than from silk. 
Some surgeons, however, are very enthusiastic in regard to the use of 
catgut when sterilized in solutions of cumol or formalin. Eecently, 
Skene, of Brooklyn, has recommended an electro-cauterization of the 
pedicle instead of ligatures, and still more recently the angeiotribe 



NEOPLASMS OF THE OVARIES 643 

has been recommended as a safe and proper substitute for all other 
means of treating the pedicle. If we meet with a pedicle especially 
broad and thicks it ma}' require ligation in several places, making 
what is called a chain ligature. 

In cutting off a tumour above the point of constriction, a button 
of tissue should be left, sufficiently large to prevent the possibility of 
the slipping off of whatever ligature is used. 

Minor, of New York, has described a variety of tumour in the 
broad ligament, which has no pedicle whatever, and has taught us how 
to enucleate it with safety from the tissue in which it lies embedded, 
ligating separately any bleeding vessels which are discovered. 

After the removal of an ovarian tumour, the other ovary should 
be examined also; if found healthy, it should be let alone. If the 
ovary is found somewhat diseased, every " conservative " effort should 
be made to preserve whatever portion of it can be properly left to 
perform its usual function. The subsequent condition of the patient 
will be much more nearly normal if sufficient ovarian tissue is pre- 
served to keep up the menstrual molimen, and thus to prevent a 
premature occurrence of the change of life, with all that that implies. 

The Toilet of the Peritoneum. — In those cases in which a simple 
ovarian tumour has. been removed without rupture or spilling its con- 
tents into the abdominal cavity, very little in the way of a " toilet " 
is required; the less manipulation of the intestines and exposure of 
the abdominal contents the better. Even the small sponge, held in 
the grasp of a long-handled forceps, which is usually passed down into 
the pelvic cavity in search of blood or other fluids, may frequently be 
omitted, and the omentum carefully drawn down over the intestines 
and the wound closed. In those cases where the omentum has been 
lacerated or torn in separating adhesions, if there is any evidence 
of bleeding, it should be carefully drawn out of the wound, spread over 
hot sterilized towels, and the bleeding points sought out and ligated. 
In most cases, simple oozing can be arrested by hot water or hot 
sponge pressure. If some portion of the omentum is considerably 
lacerated, a ligature may be applied behind the leaking surfaces and 
the omentum tissue boldly cut away. In those cases where there has 
been much hemorrhage from tissues lacerated by the separation of 
adhesions, or the abdominal cavity has been soiled and possibly in- 
fected by fluids from malignant tumours, or by pus from infected 
abscesses, the cavity should be thoroughly irrigated with hot normal 
salt solution. In that class of cases which have heretofore required 
transfusion, large quantities of the normal salt solution may be 
poured into the abdominal cavity and left there to float the intestines, 
to prevent the immediate occurrence of adhesions, and to perform the 
office of transfusion by being absorbed into the circulation. The 
great thirst which usually follows ovariotomy, as well as all other 
abdominal operations, is much alleviated by the salt solution. Xo 
germicide of sufficient strength to be of any service in destroying 



644 A TEXT-BOOK OF GYNECOLOGY 

germs is ever permissible inside the abdominal cavity. If it were suf- 
ficiently powerful to kill the germs, it would at the same time kill 
the patient. 

General irrigation of the abdominal cavity is not employed at the 
present day as frequently as it was formerly. A localized collection 
of infectious fluid, readily absorbed by a sponge, might be carried to 
remote parts of the cavity by general irrigation and set up an incur- 
able septic peritonitis. The abdominal wound may be closed by what 
have been described as through-and-through sutures, or the tissues may 
be brought together by from three to six tiers of sutures according to 
the preference of the operator. When the through-and-through sutures 
are used, four to the inch should be employed. The object of the more 
thorough suturing is the more sure prevention of ventral hernia. Taber 
Johnson doubts whether half a dozen layers of sutures accomplish this 
purpose more thoroughly than well-applied through-and-through su- 
tures. From the investigations which he has been able to make, 
about the same number of cases of ventral hernia occur with one 
method as with another. As ventral hernia will be prevented by per- 
fect union of the fascia, after the application of the through-and- 
through sutures Taber Johnson is in the habit of inserting one silk- 
worm gut to the inch through the edges of the fascia, and thus secur- 
ing permanent approximation of its edges when tied. If union fails 
to occur, these nonabsorbable, buried sutures will hold it together for- 
ever. Some operators prefer silver wire for this purpose. 

If a fixed rule, always to close the abdominal wound with five or six 
layers of sutures, is adopted, the operator will not infrequently find 
himself spending more time over the closing of the abdominal wound 
than over all the other steps of the operation together. 

Drainage. — The present practice of ovariotomists is, so far as 
possible, to avoid drainage. Not a few gynecological surgeons have 
recently reported that they have not drained the abdomen after ovari- 
otomy for a number of years, even in their worst cases, and that they 
find no increase in their mortality. In those cases where drainage 
is considered absolutely necessary on account of the soiling of the 
peritoneum with infectious fluid, gauze drainage is used much more 
frequently than the glass tubes. Neither the glass tube, nor gauze 
drainage, is likely to be of much service after twenty-four hours ; for 
the glass tube does not drain any greater area than the little pocket 
at its distal extremity, on account of its being shut off from the 
abdominal cavity by lymph which has been poured out around it; 
while gauze, after it has once become wet, ceases to absorb more fluid, 
and only drains by lying in contact with dry gauze which may absorb 
from it. 

Dressings. — The dressings applied to an ovarian wound need hardly 
differ from those applied after any up-to-date aseptic operation. The 
practice of dusting iodoform powder over the edges of the wound has 
been abandoned. The wound should be thoroughly dried and 



NEOPLASMS OF THE OVARIES 645 

cleansed, and pads of gauze placed on each side of the row of sutures, 
and another, thicker gauze pad laid over them both. A combined 
dressing is then applied over the abdomen from hip to hip and secured 
by broad strips of adhesive plaster. A thin flannel or many-tailed 
bandage may now be applied, securely holding the dressings perma- 
nently in position. These do not require to be changed for seven days, 
if all goes well. If the tumour has been very large and the abdom- 
inal walls have sunk in considerably, the depressed spaces should be 
filled out by sterilized absorbent cotton. 

After-treatment. — The after-treatment of a simple case of ovari- 
otomy amounts to little more than keeping the patient clean and let- 
ting her alone. Give her a cheerful nurse, protect her from visitors, 
and encourage her to get well. Little medicine is required beyond 
what is necessary to move the bowels, quiet restlessness, and produce 
sleep. As soon as the patient has had a good operation from the 
bowels she is considered convalescent. This is usually produced by 
small doses of calomel, followed by teaspoonful doses of Kochelle salts 
every two hours until the bowels move. It was formerly the custom 
to withhold all food or drink for twenty-four hours. The piteous 
appeals of the patient for water to quench her thirst were stubbornly 
resisted, but we find by increasing experience that patients may, with- 
out injury and greatly to their comfort and happiness, take frequent 
sips of hot water or tea a few hours after their recovery from the 
anaesthetic, unless tormented by the ether nausea. Patients, it is 
found, may also take with benefit small draughts of beef essences or 
concentrated forms of liquid nourishment after the first twelve hours. 
If this disagrees with them, it should be withheld for a while. It is 
best to adhere to the rule that patients should not see visitors for a 
week after their operation. Exceptions will occur where a discreet 
mother or husband may see the patient a few days after her opera- 
tion with great benefit. The patient should be urged to pass her 
water in a bedpan. The use of the catheter in the hands of the most 
skilful nurse has often produced urethral or vesical irritation. Its 
routine use for several days after all ovariotomies should be aban- 
doned. 

The use of opium should be avoided when possible, as the patient's 
pain, nervousness, and restlessness, are generally increased and pro- 
longed by the unwise use of this drug. There will occur, now and 
then, a case where a hypodermic of morphine or codeine will quiet 
restlessness and produce the greatest amount of comfort, with no 
harm whatever following its use; but the routine employment of opi- 
ates after ovariotomy is full of mischief and trouble. 

If the bowels are painfully distended by collections of gas, the 
introduction of a rectal tube gives much relief. If, upon removal of 
the dressing on the seventh day, the wound is found well united, the 
sutures may be all gently removed. If union is not perfect, or if 
stitch-hole abscesses have occurred, a few of the stitches can be left 



646 A TEXT-BOOK OF GYNECOLOGY 

for two or three days longer. If the wound is perfectly dry, no treat- 
ment is necessary, but narrow strips of rubber plaster may be placed 
across the wound to hold it securely while a firmer union is taking 
place. The gauze dressings should be changed and held in position by 
a firm clean binder. 

It is better for the patient to remain in bed three weeks. Young, 
vigorous patients, who have had an uninterrupted recovery, have gone 
home from the hospital at the end of two weeks without harm, but 
this is not a safe practice. If no pus is present, the wound may not 
require dressing oftener than once a week. At the end of the fourth 
week, the patient may safely be allowed to return to her home, but 
should be provided with an abdominal bandage, which she should be 
advised to wear for six months or a year, and to abstain, so far as pos- 
sible, from overwork, lifting heavy weights, or any straining occupa- 
tion which might have a tendency to produce ventral hernia. 

Accidents. — Accidents may occur during ovariotomy from the ad- 
ministration of the anaesthetic, or from the stripping off of the peri- 
toneum from the abdominal walls or the intestines. The cyst wall 
may be accidentally ruptured while separating adhesions. Bleeding 
points may be overlooked, and the patient's life lost from hemor- 
rhage after the closure of the incision. Ligatures have slipped off the 
pedicle, catgut has become untied; intestines, omentum, or bladder, 
have been injured when opening the abdominal cavity, or torn while 
separating adhesions. None of these accidents should occur in the 
hands of the average conscientious operator. Sponges, forceps, scissors, 
rings, and eyeglasses, have all been lost in the abdominal cavity during 
an operation, and have been searched for subsequently or found during 
a post-mortem. 

Obstruction of the bowels may be caused by paralysis of, or kinks 
or twists in, the intestines. Fistulse may follow the use of infected 
ligatures, and ventral hernia may occur to torment the patient in 
some cases to such an extent, that her sufferings are greater after her 
operation than they were from the condition which made the opera- 
tion necessary. 

Mortality. — The average mortality at the hands of all operators 
the world over, is probably about 10 per cent. Experts in the prin- 
cipal cities of the world will often report a series of 100 cases, how- 
ever, with no mortality whatever. Leaving out the cases of malig- 
nancy and the unexpected accidents, the mortality of ovariotomy in 
the hands of experienced operators will probably not range above 3 or 
5 per cent, while during the first half of the present century the mor- 
tality lingered very closely around 50 per cent. We are proud and 
happy to state that as the new century is dawning the mortality is 
reduced to less than 5 per cent. 

Incomplete Ovariotomy. — This is sometimes made necessary by the 
character of the growth, and by the extent and density of its adhe- 
sions. Proliferating cysts, the pedicles of which have been subjected 



NEOPLASMS OF THE OVARIES 647 

to even temporary torsion, exposed to traumatism or infection, or have 
become the seat of secondary malignant changes, may become so 
intimately involved with the intestines that they can not be removed 
without irreparable, if not fatal, injury to the latter. Under such 
•circumstances, it may be found expedient to remove a part of the cyst 
wall, stitching the remainder to the margins of the intestinal incision, 
an operation which Pozzi designates as the marsupialization of the 
patient. It is always a matter of great importance to determine when 
this step should be taken. As a rule exemplified in the reported cases 
of Vander Veer (New York Medical Journal, 1893), it should be done 
in the presence of the foregoing complications, particularly when the 
operation has already been so long or so difficult that, if still further 
prolonged, the patient will die from hemorrhage or shock. In fixing 
the edges of the sac to the edges of the abdominal wound, it is impor- 
tant to see that all bleeding points in the former are brought under 
control. This can be accomplished, as a rule, by means of ligatures; 
but in exceptional cases, the cyst walls will be found to be of such an 
embryonic character that they will not sustain a ligature, when it will 
become necessary to resort to the cautery, to styptics, or to sponge 
packing, to control the bleeding. Cases have been reported in which 
the remnant of tumour tissue has sloughed away through the opening 
left by this operation, the patient making an eventual recovery. For- 
tunately, complications rendering this course necessary are now of 
relatively rare occurrence. 

Ovariotomy during Pregnancy. — This is frequently an operation 
of expediency. The mortality from this operation, if done during 
the first five or six months of pregnancy, is not higher than when done 
in a nonpregnant state. Olshausen has performed the operation 26 
times without a single death. The danger to both mother and child 
increases with the progress of gestation. The results are most fa- 
vourable for the mother in the second, third, and fourth months, and 
for the child in the third and fourth months — although favourable 
results are obtained even in the last month of gestation. The liability 
to rupture renders ovariotomy the desirable alternative at any stage 
of pregnancy. " Palliative " treatment by puncture of the cyst does not 
palliate; on the contrary the cyst rapidly refills, with an increased 
tendency to adhesion and rupture. 

Successful cases of double ovariotomy during pregnancy have been 
reported by Vander Veer, Knowsley Thornton, Gardner, Montgomery, 
Munde, Potter, Bovee and others. Potter's case, reported to the 
American Association of Obstetricians and Gynecologists (vide Trans- 
actions, 1888), was probably the first case in America in which a 
woman went to full term after a double ovariotomy done during the 
course of gestation. In this case, Potter operated in the latter part 
of the fourth month; there was a tendency to rhythmic uterine con- 
tractions on the seventh day, but these speedily subsided, after which 
she went to full term without incident. These cases must be accepted 



648 



A TEXT-BOOK OF GYNECOLOGY 



as establishing the safety of the operation — although the liability of a 
double ovariotomy to induce abortion must be considered as greater 
than that which pertains to the operation upon one side only. 

The results of ovariotomy during pregnancy are favourable. 
Dsirne reports 135 cases with 8 deaths, being a mortality of 5.9 per 
cent. Subsequent reports from individual operators do not tend to 
increase the mortality. The influence of ovariotomy, under these cir- 
cumstances, upon pregnancy, has been ascertained with approximate 
accuracy. Olshausen found pregnancy interrupted in about 20 per 
cent of his cases. While Dsirne (Archiv fur Gijnakologie) found that 
it was interrupted in 22 per cent of 114 cases which he collected. This 
seemed to vary somewhat according to the stage of gestation, as indi- 
cated by the following table by Dsirne : 



At Months. 


No. cases. 


Interruptions of 
pregnancy. 


Percentage. 


2 


11 

28 

21 

10 

11 

5 

5 

1 


5 
4 

2 
4 
4 
3 

2 
1 


45.5 


3 


14.3 


4 


9.5 


5 

6 


40.0 
36.4 


7 


60.0 


8 


40.0 


9 


100.0 







Bovee {American Journal of Obstetrics) has tabulated 23 cases in 
which extirpation of the uterine appendages has been practised in the 
presence of pregnancy. Ten of the cases were for ovarian cyst, while in 
8 out of the 10, the cysts were double; all the patients recovered. 



CHAPTER XLII 

ECTOPIC PREGNANCY 

Historical resume — Definition — Etiology — Classification — Course and termination 
— Histology — Symptomatology — Diagnosis — Treatment. 

Historical Resume. — The term ectopic pregnacy, from Zktottos (e*, 
out of, and t6tto<s, a place), was suggested by Dr. Robert Barnes in 
lieu of the familiar term extrauterine pregnancy, to designate a mal- 
position of the fertilized ovum. It has been very generally accepted 
into gynecological nomenclature as more accurately designating the 
pathology of this most interesting condition. Since the fertilized 
ovum may be arrested and may develop in that portion of the tube 
passing through the uterine walls, it is apparent that such a pregnancy 
would not be extrauterine but would be ectopic. 

This pathologic condition until recently constituted a dark chapter 
in gynecological surgery. It was altogether misunderstood in its 
etiology and pathology, its symptoms were misinterpreted, and hun- 
dreds of deaths occurred annually which would now be prevented by 
timely surgical intervention. Following the possibilities of aseptic 
surgery, this great achievement was accomplished by one man, Lawson 
Tait, whose genius illumined the entire subject and established meth- 
ods of cure that approach perfection. The first correct interpretation 
of the pathology of this abnormity, which has such heavy mortality, 
was attained by Bernutz and Goupil, two able French observers who 
have made an exhaustive study of the disease by post-mortem exami- 
nation. The work of these eminent students of pathology was trans- 
lated into English in 1866 and widely circulated under the auspices 
of the New Sydenham Society by Alfred Meadows. The work was 
ably reviewed in America at great length by Parvin, yet no surgeon 
adopted the true pathology of extrauterine pregnancy as therein set 
forth. John S. Parry, of Philadelphia, made a valuable contribution 
to the subject in a book published in 1876, but did not elucidate the 
pathology or recognise the surgical aspects involved when, through 
the advance of aseptic surgery, it became practicable to open the abdo- 
men with safety for the relief of grave and obscure intra-abdominal 
disease. Tait dealt with the subject in a masterly way. Utilizing the 
post-mortem researches of Bernutz and Goupil and the clinical obser- 
vations of Parry, he elucidated the entire subject, classified its various 
types and phases, and formulated and demonstrated with - the mind 

649 



650 A TEXT-BOOK OF GYNECOLOGY 

of a genius and the hand of a master, therapeutic resources which have 
placed his name forever among the benefactors of science and 
humanity. 

Definition. — The term ectopic, or extrauterine, pregnancy is, as 
already stated, applied to a malposition and abnormal development of 
the fertilized ovum. After fertilization the ovum may establish its 
habitat within the ovary (ovarian pregnancy), within any part of the 
free Fallopian tube (tubal pregnancy), or within that portion of the 
tube which passes through the uterine wall at the cornu (interstitial 
pregnancy). Primarily, ectopic pregnancy is almost invariably situ- 
ated in the Fallopian tube, and ovarian pregnancy is so very rare that 
its existence has been denied both by pathologists and surgeons. 
However, specimens have been studied carefully by competent observ- 
ers, which establish the fact that this anomaly actually does occur; 
but the instances are so few as to render ovarian pregnancy an ex- 
treme rarity in clinical experience. Ectopic pregnancy, as a rule, is 
tubal. 

Etiology. — In considering the etiology of ectopic, or, preferably, 
tubal pregnancy, it is necessary to review to some extent the physiology 
of the Fallopian tube and the impregnation of the ovum. The tubes are 
the ducts through which the ovum, when discharged from the ovary, 
travels into the uterine cavity; hence their name, oviducts. From 
observations and experiments made on the lower animals, it appears 
probable that the transport of the ovum is effected mainly, if not ex- 
clusively, through the action of the ciliated columnar epithelium lining 
the tubal mucous membrane. It is quite probable that peristaltic 
movements of the tubes, if they take any part at all in the transport of 
the ovum, play a minor role only. We have every reason to believe that 
in the human being, as is the case in some of the lower animals, judg- 
ing from observations actually made, the fertilization of the ovum by 
the spermatozoa occurs in the outer half or outer third of the tube. 
Normally, an ovum fertilized in the tube will, in a few days, travel 
into the uterine cavity, and will there become implanted for further 
development. The question arises, What cause or causes are respon- 
sible for an impregnated ovum remaining and becoming implanted in 
the tube, instead of passing into the uterus ? Certain alleged causes, 
formerly frequently cited as responsible for tubal pregnancy, such 
as inflammatory diseases of the uterus and tubes, must be absolutely 
discarded. We know now that these very conditions, instead of being 
the cause of tubal pregnancy, make a woman sterile for the time 
being, and therefore exclude tubal, as well as normal uterine preg- 
nancy. It is impossible here to go into a discussion of all the alleged 
causes of tubal pregnancy, since most of them really deserve detailed 
consideration. Herzog, who has carefully studied the gross and fine 
anatomy of over 30 cases of tubal pregnancy, believes that, in a con- 
siderable proportion, congenital anomalies of the tubes must be held 
responsible for the establishment of an ectopic gestation. Herzog has 



ECTOPIC PREGNANCY 651 

certainly twice, and possibly three times, seen tubal pregnancy in a 
diverticulum of the main canal (Fig. 277), and once in an accessory 
blind fimbriated extremity. (Henrotin and Herzog. Anomalies du 
Canal de Miiller, comme cause de grossesse ectopique. Revue de 
cliirurgie abdominale, 1898. — Henrotin and Herzog. Very Early 
Eupture in an Ectopic Pregnancy in a Diverticulum. New York Med- 
ical Journal, 1899.) Several times he noticed that the tubal canal in 



Fig. -277. — " A diverticulum of the main canal." — Hekzog. 

which the pregnancy occurred was unusually tortuous, so that the 
road from the fimbriated extremity to the ostium internum of the 
tube, which the ovum would have to traverse, was an unusually long one. 
The theory that congenital anomalies are the cause of tubal pregnancy 
is supported by facts. 

Another cause assumed by Herzog can not yet be supported by 
direct, actual observations. He is of the opinion that the tubal mu- 
cosa takes part to a certain extent in menstruation. Xormally, the 
menstrual changes of the tubal mucosa are insignificant, compared 
with those of the uterine mucosa. Occasionally, however, the tubal 
mucous membrane shows intense menstrual changes, which may be so 
pronounced as to lead to the formation of a hematosalpinx. We can 
hardly doubt that the menstrual changes of the uterine mucosa pre- 
pare the latter for the reception of an impregnated ovum, which, as 
appears most probable from the latest contributions upon the sub- 
ject, eats or corrodes its way into the substance of the uterine mucosa 
by the aid of a phagocytic trophoblast (see page 657). Whenever 
the tubal mucous membrane undergoes extensive menstrual changes, 
it must become a soil into which an impregnated ovum can easily 
implant itself. It therefore appears very probable to Herzog that 
such well-marked menstrual changes in the tubal mucosa frequently 
become the cause of an ectopic implantation of a fertilized ovum. 

So far as our exact knowledge goes to-day. we must, however, con- 
fess that we are unable in most cases of ectopic gestation definitely to 
give the exact causes of this occurrence, often so very grave in its 
consequences. That our knowledge as to the etiology of most cases 
of ectopic gestation is yet so very deficient, lies in the very circum- 



652 



A TEXT-BOOK OF GYNECOLOGY 



stances surrounding this occurrence. In addition, we must not forget 
that when we obtain a specimen for examination post operationem or 
post mortem, hemorrhages and secondary changes have often so 
mutilated the parts that exact anatomical studies frequently become 
utterly impossible. 

Classification. — The varieties of tubal pregnancy, which are distin- 
guished according to the anatomical seat of the developing ovum, are 
as follows : If the ovum is in the part of the tubal canal which per- 
forates the uterine wall, we speak of it as an interstitial pregnancy. 
This variety is not very frequently seen. There have been reported 
erroneously as interstitial pregnancies, cases which were cornual or 
where the ovum was located in a blind prolongation of Gartner's duct, 
which sometimes extends down into the cervix. In interstitial tubal 
pregnancy, the developing ovum frequently pushes its way into the 
uterine cavity, and we then have the condition known as tubo-uterine 
gravidity. In it, the gestation sac may be of fair thickness, and the 
pregnancy may go on to full term and terminate fairly normally. 

The second vari- 
ety of tubal preg- 
nancy is present 
when the ovum is 
found in the middle 
part of the tube; in 
which case we are 
dealing with an isth- 
mic tubal pregnancy, 
or tubal pregnancy 
par excellence {gravi- 
ditas tubaria pro- 
pria). The placenta 
in these cases gener- 
ally has its seat in 
the lower or poste- 
rior part of the tube 
wall. The gestation 
sac in this variety is 
generally very thin 
and the danger of 
rupture very great. 
Here we also some- 
times find peduncu- 
lated gestation sacs. 

Probably the most 
frequent variety is 
that of a development of the ovum in the outer third of the tube or am- 
pulla. This kind of ectopic gestation is known as ampullar pregnancy. 
The widest part of the Fallopian tube, the ampulla, naturally offers the 




Fig. 278. — The case [of ectopic pregnancy] of Joseph Price. 
— Heezog (page 653). 



ECTOPIC PREGNANCY 



653 



most favourable conditions for an undisturbed development of an im- 
planted ovum. So we frequently find ampullar pregnancy develop much 
beyond the earlier months of gestation. On the other hand, the funnel- 
shaped ampulla favours abortion of 
the ovum. The latter sometimes 
partly protrudes out of the ampulla 
into the general peritoneal cavity, and 
then we have the condition known as 
tubo-abdominal pregnancy. This is, 
however, not the rule, but the excep- 
tion in ampullar pregnancy, because 
there exists already in the earlier 
months a tendency of the fimbriated 
extremity to become closed by aggluti- 
nation of the plica?. It also occurs 
that the ovum in ampullar pregnancy 
protrudes into, and partly develops in, 
cystic portions of the ovary. This 
condition can probably supervene 
only when, early in the course of or 
prior to ectopic gestation, the fimbri- 
ated extremity becomes adherent to 
the ovary and forms what is called a 
tubo-ovarian cyst. The form of 
ecoptic gestation then established is 
called tubo-orarian pregnancy. That 
primary true ovarian pregnancy occurs 

as a matter of fact, is demonstrated by well-authenticated cases, notable 
among which is an advanced case by Price (Figs. 278, 279) in which 
the child went to term, projecting on either side from the enlarged 
ovary; and an early case by Withrow (Fig. 
280), the fact of impregnation in the latter 
having been established by careful microscopi- 
cal studies by Whitacre. Abdominal and in- 
traligamentous pregnancies are developed 
from primary tubal gestation. Intraligamen- 
tous pregnancy may be brought about in a va- 
riety of ways. There may be a rupture of the 
lower part of the tube wall with more or less 
hemorrhage and the escape of the ovum be- 
tween the folds of the broad ligament. The 
growing ovum may so stretch the lower 
segment of the tube that it becomes entirely 
membranaceous, and the sac so formed may 
unfold the two leaves of the broad ligament. This splitting apart of 
the layers may also be brought about in such a manner that the ovum 
completely rarefies the wall of the Fallopian tube at some point, and 




Fig. 279. — " The child went to term 
projecting on either side from the 
enlarged ovary." — Herzog. 




Fig. 280. — "An early case 
by Withrow." — Herzog. 



654 A TEXT-BOOK OF GYNECOLOGY 

produces a slit through which it escapes to a spot between the folds of 
the broad ligament where further development takes place. 

Abdominal pregnancy can be brought about in a variety of ways. 
An ovum located in the tube may be aborted through the ostium 
abdominale into the general peritoneal cavity. If its placenta is not 
too seriously damaged, the embryo may, after tubal abortion, go on 
developing. Eupture of the tube may send the ovum into the general 
abdominal cavity. The embryo may continue to develop not only 
when, after primary rupture, its membranes are intact, but even after 
rupture of the foetal membranes has taken place. 

Course and Termination of Ectopic Gestation. — While almost every 
variety of ectopic gestation may go on to full term, most cases ter- 
minate in the earlier months of development by rupture or abortion. 
Eupture, in the majority of cases, is brought about by preceding 
larger or smaller hemorrhages. The latter are of two kinds: small 
hemorrhages from enlarged tubal vessels into the oedematous and in- 
flamed tube wall, and hemorrhages from the utero-placental sinuses 
into the intervillous space. The utero-placental sinuses in tubal preg- 
nancy are opened in a more irregular and more extensive manner by 
the syncytium than is the case in normal uterine pregnancy, and the 

stretching of the tube wall by the 
enlarging ovum early establishes a 
tendency to extensive hemorrhages 
from the utero-placental sinuses 
into the intervillous space. These 
hemorrhages frequently dissect 
the ovum loose from the gesta- 
tion sac, and rupture is often initi- 
ated in this manner. But even 
if a rupture does not occur, the 
embryo may be killed and the 
ovum arrested in further develop- 

.biG. 281. — "The embryo, from seven to . . o ,-i ■ 

eight weeks old, looked perfectly fresh ment m consequence of the m- 
and normal."— Herzog. tervillous or interplacental hemor- 

rhages. Herzog examined 2 cases 
of tubal pregnancy operated on before rupture had occurred. In 1 
case, the embryo, about five weeks old, was badly macerated. In 
the other, the embryo, from seven to eight weeks old, looked per- 
fectly fresh and normal (Fig. 281). It was found, however, in both 
cases that extensive interplacental hemorrhages had taken place, 
and that the villi in both cases were badly crushed and in an 
advanced stage of degeneration. If this is the case, the embryo de- 
pending for its nutrition upon the villi must, of course, perish in a 
short time. Herzog thinks that interplacental hemorrhage very fre- 
quently precedes rupture for quite an interval of time, because often, 
even when operation is performed shortly after the symptoms of rup- 
ture become manifest, one finds the villi in an advanced state of de- 




ECTOPIC PREGNANCY 655 

generation. When more or less extensive hemorrhage occurs, either 
into the tissues of the tube wall or into the intervillous space, rup- 
ture generally takes place in consequence of pressure. The hemor- 
rhage after rupture increases as a rule very much, and it may become 
fatal. The rupture generally occurs at the place where the placenta 
has been attached. Here, the tissues of the tube wall are often 
thinned out very much. The cellular elements, particularly the mus- 
cle bundles, have been pushed apart, the interstices created are filled 
out by a serous exudate (oedeniatous infiltration), and almost the 
whole thickness of the sac is undermined by the phagocytic action of 
the syncytium. What becomes of the ovum after rupture, has been 
indicated already in discussing intraligamentous and abdominal preg- 
nancies. 

Tubal abortion is brought about by either of two causes or by a 
combination of the two. These causes are hemorrhages and contrac- 
tions of the tube wall. The latter will, however, be impossible when 
the muscular coat of the tube has been weakened very much by rare- 
faction and cedematous infiltration. 

The embryo in ectopic gestation, as a rule, no matter what occurs, 
is arrested in its development and dies. Even if it goes on to full 
development, it must perish unless relieved artificially from its ectopic 
position. But interstitial tubal pregnancy, when leading to tubo- 
uterine gestation, may terminate in a natural manner without artificial 
aid. If the development of the embryo in ectopic pregnancy is arrested 
early in consequence of rupture or abortion, and if the foetus gets into 
the general peritoneal cavity, it is speedily absorbed, so that after a 
few days there is no trace left of it. Older embryos, arrested in devel- 
opment, become the subject of either mu nullification and lithopcedion 
formation or of maceration. The latter process usually takes place if 
the embryo has been deprived of its protecting foetal membranes. 
Maceration brings with it the danger of septic infection or putrid 
changes. The process of calcification of an ectopic ovum may assume 
one of three forms. If only the foetal membranes become infiltrated with 
lime salts, we speak of a litliokelyphos; if the foetal membranes and 
the superficial tissues of the foetus are incrusted, we speak of litho- 
kelyphopcedion, while lithopcedion proper signifies the condition when 
the embryo alone presents as a calcareous mass. Lithopaedion 
formation is not infrequently found after the death of a fully de- 
veloped foetus has been brought about by spurious labour. A litho- 
paedion may often remain for years in the abdominal cavity without 
giving rise to trouble, yet may ultimately bring trouble about after 
having been harmless for a long period of time. Tubal gestation may 
be a twin pregnancy, and cases of bilateral tubal pregnancy have been 
observed. Repeated tubal pregnancies have likewise been recorded. 
Henrotin (loc. cit., p. 386) saw an abdominal pregnancy brought about 
by an attempt of the patient to produce an abortion in the seventh week 
of normal uterine gestation. A sharp instrument inserted into the 



656 A TEXT-BOOK OF GYNECOLOGY 

uterine cavity perforated the fundus. The ovum escaped into the 
general peritoneal cavity and kept on developing, the placenta spread- 
ing from the uterine cavity to the peritoneal coat of the womb. This 
pregnancy had to be terminated by an operation during the fifth month 
of gestation. 

The uterus in ectopic pregnancy undergoes hypertrophy. The 
latter is of course mostly confined to the muscular coat. The uterine 
mucous membrane is changed into a decidua. That this is the case 
was maintained years ago by Langhans and others. There have been 
those, however, again and again, who assert that there is no uterine 
decidua formed in tubal pregnancy. Herzog, who has studied uterine 
scrapings from a number of cases of tubal pregnancy, finds that a 
decidua is formed. It is not materially different from the decidua vera 
as formed in normal uterine pregnancy. This decidua is frequently 
shed at the time of rupture, abortion, or when the embryo dies from 
any cause. This accounts for the fact that a number of observers, 
making an examination at an improper time, have not found any 
uterine decidua and have been misled into the belief that none is 
formed in tubal pregnancy. The uterus as a whole in ectopic preg- 
nancy enlarges to the size of a womb in the third or fourth month 
of normal pregnancy. Beyond this stage it rarely, if ever, hyper- 
trophies; it then either remains stationary or frequently even be- 
comes gradually smaller. This is always the case as soon as the 
embryo is arrested in its development by rupture, abortion, or 
otherwise. 

The Histology of Tubal Pregnancy. — The study of the microscopic 
anatomy of tubal pregnancy is by no means an easy matter. By far 
the greater number of cases are only operated upon after primary or 
even secondary hemorrhages have occurred, and the material obtained 
under such conditions is often eminently unsuited to draw trustworthy, 
valuable conclusions from, as to histogenetic details. Even in cases 
operated on before any rupture has taken place, there may have oc- 
curred intervillous hemorrhages, which will greatly disturb the normal 
relation of the component parts of the placenta. Of a large number 
of cases of ectopic gestation, only a comparatively small percentage can 
be relied upon to furnish valuable material for microscopic examina- 
tion, and even this can only be properly interpreted by one who has 
been a faithful, patient student of the histogenesis of the normal 
uterine placenta, a subject itself offering considerable difficulties. 
These, of course, become greatly augmented when we deal with an 
ectopic implantation of the ovum. The following short description 
of the histology of tubal pregnancy, Herzog bases upon the microscopic 
examination of over 30 cases. In a book of this kind it would, of 
course, be very much out of place to discuss in detail all the contested 
points, of which there are quite a number, in regard to the histogenesis 
of the normal placenta as well as of that of tubal pregnancy. It will 
be necessary to be brief and somewhat dogmatic. 



ECTOPIC PREGNANCY 



657 




Fig. 282. — "A differentiation into a decidua compac- 
ta and a decidua spongiosa." — Herzog (page 658). 



From observations recently made by Van Heukelom and Peters 
upon very young human ova obtained in situ in the uterus, it appears 
that the human ovum, like that of other mammals, is surrounded, soon 
after fecundation, by a layer 
of solid ectoblast, called 
" trophoblast." In this, many 
nuclei but no individual cell 
boundaries are distinguish- 
able. The trophoblast, as 
it appears, has phagocytic 
properties and enables the 
ovum to corrode its way into 
the uterine mucosa, which at 
this early time has already as- 
sumed the character of the 
decidua. If this is the normal 
modus operandi, and the ob- 
servations cited very strongly 
suggest that it is so, it is easy 
to understand how an im- 
pregnated ovum may implant 
itself into the tubal mucosa. 

The mode of implantation would be exactly the same as in the uterus, 
because it depends chiefly, if not exclusively, upon structures and prop- 
erties of the fertilized ovum itself. From the trophoblast are later on 

developed the villi with their 
two ectodermal layers, viz., 
the inner cell layer of Lang- 
hans and the outer, nucle- 
ated plasmodium, the syn- 
cytium. The very first 
stages of placental formation 
have never been observed in 
ectopic pregnancy. 

If we turn to what has 
been observed, the following 
outlines may be given: The 
early placenta fcetalis in 
tubal pregnancy is in no 
way different from the same 
structure in normal uterine 
development of the ovum. 
The villi possess a meso- 
dermal core with foetal blood 
vessels and a double ecto- 
dermal lining, the cell layer of Langhans and the syncytium. 
The placenta materna presents a decidua serotina not so well de- 
43 




Fig. 283. — "The pseudo-gland spaces . . . have been 
formed by the deeper recesses between the origi- 
nal plica?." — Herzog (page 658). 



658 A TEXT-BOOK OF GYNECOLOGY 

veloped as in normal uterine pregnancy, but showing large typical 
decidual cells and a division into a decidua compacta and a decidua 
spongiosa (Fig. 282). The open spaces in the spongiosa are fre- 
quently lined by high columnar epithelium. This may also, how- 
ever, be more or less flattened, or it may have degenerated entirely 
and be found to have dropped off into the lumen of the pseudo-gland 
spaces. The latter have been formed by the deeper recesses between the 
original plica? of the tubal mucous membrane (Fig. 283). The changes 
which the plicae undergo in tubal pregnancy consist in a club-shaped 
thickening and a transformation of the fine connective tissue spindle 
cells into elements of the character of decidual cells. The plical blood 
vessels become enormously dilated to form the tubo-placental blood si- 
nuses. Neighbouring plicae become confluent at their higher parts, and 
this gives rise to the formation of the upper compact layer of the de- 
cidua, while the deeper recesses between the plicae give rise, as already 
stated, to the pseudo-gland spaces, forming in this manner the lower 
spongy layer of the decidua. The formation of the decidua vera is simi- 
lar to that of the serotina, but the vera as a rule does not extend very 
much beyond the place of insertion of the ovum. The formation of a 
decidua reflexa, or capsularis, in tubal pregnancy has been denied. Her- 
zog has, however, reported an instance that is beyond doubt. If the 
above-described mode of implantation of the human ovum is correct, as 
it most probably is, then the formation of a capsularis, or decidua re- 
flexa, in tubal pregnancy is very easily explained. Herzog has previously 
insisted upon the fact that a decidua reflexa must always be formed in 
tubal pregnancy. He says in connection with this subject (The Practice 
of Obstet?*ics oy American Authors, 1899, p. 362): "At an early period 
in uterine gestation an intervillous space filled with maternal blood, 
bounded on the outside throughout most of its extent by the decidua 
reflexa, surrounds the whole chorion. In, tubal pregnancy, therefore, 
there must also always be formed a decidua reflexa, because an intervil- 
lous space capable of maintaining the maternal blood can be formed 
only by a decidua reflexa, unless we assume that the tube very easily be- 
comes obliterated on both sides of the ovum. Since we have no proof 
at all of such a very improbable occurrence, a decidua reflexa becomes 
an absolute necessity for the establishment of the intervillous space." 
This was written before the observations of Peters on a very young 
human ovum were published. These have since furnished some much- 
desired elucidation about the establishment of the intervillous space 
and the formation of the decidua reflexa. This brings us to the ques- 
tion of the intervillous space in ectopic pregnancy. How a recent 
writer (Kuehne, Beitrage zur Anatomie der Tubarschivangerschaft, Mar- 
burg, 1899) can state with all seriousness that an intervillous space 
with maternal blood is never formed in tubal pregnancy, is a matter 
difficult to understand. If we consider that tubal pregnancies have 
gone to full term and have been terminated by the delivery of a living 
child, we must insist from merely theoretical reasoning upon the estab- 



ECTOPIC PREGNANCY 



659 




Fig. 284. — " An intervillous space." — Herzog. 



lishment of an intervillous space with maternal blood. Brit aside from 
any theoretical reasoning, we find favourable cases enough which per- 
mit us to recognise an inter- 
villous space (Fig. 284). ^*&K~% 

The changes going on in 
the muscularis of the tube 
consist in a hypertrophy of 
the muscle cells. As in the 
uterus, their number does 
not seem to be increased, but 
each individual fibre be- 
comes enlarged. The num- 
ber of muscle cells normally 
found in the tube is, of 
course, very small compared 
with the number found in 
the muscularis of the uterus. 
The gestation sac formed in 
tubal pregnancy consequent- 
ly must soon be very inade- 
quate in thickness, and cedematous infiltration and inflammatory 
changes must take place (Fig. 285). This, of course, as is seen in every 
single case, always comes to pass. Microscopic examination of the 
gestation sac shows that the bundles of muscle fibres become separated 

by interstices. These are 
often filled out with fibrous 
connective tissue, but fre- 
quently we only find an 
cedematous or serous mate- 
rial between the muscle bun- 
dles. The whole tube wall, 
including the decidua, is in- 
filtrated with cellular ele- 
ments of an inflammatory 
type, such as polynuclear 
leucocytes and lymphocytes; 
plasma cells are likewise 
found. This inflammatory 
reaction is brought about by 
coagulation necrosis, in con- 
sequence of pressure and 
pulling and smaller and 
larger apoplectic insults 
from enormously enlarged tubal vessels. But all of these changes, 
which as a rule only become pronounced when the ovum has reached 
a certain size, do not seem to be sufficient to explain very early 
ruptures. It appears to Herzog that one of the most important, if 




Fig. 285. — " (Edematous infiltration and inflamma- 
tory changes must take place." — Herzog. 



A TEXT-BOOK OP GYNECOLOGY 



not the most important, factor in the production of early rupture 
in tubal pregnancy, is furnished by the behaviour of the syncytium 
The latter in tubal pregnancy displays greater phagocytic properties 
or greater penetrating powers than in normal uterine gestation. In 
the latter we see the syncytium often penetrate deeply into the de- 
cidua. But it appears that the uterine muscularis offers to the fur- 
ther progress of the syncytium an obstacle as a rule unsurmountable. 
It is different in tubal pregnancy. Here there is no strong, solid, 
dense muscularis. We have on the contrary a rarefied, cedematous 
tissue, and in it one can frequently see that the syncytium pene- 
trates through almost the entire thickness of the gestation sac. It 
is this circumstance which appears to Herzog as of the greatest 
importance in bringing about the conditions which lead to early 
rupture in tubal pregnancy at a time when the pressure of an en- 
larging ovum can not yet be held as adequately responsible for the 
accident. The extensive penetration of the syncytium, as found in 

specimens of tubal preg- 
nancy, reminds one forcibly 
of the syncytial proliferation 
as found in placentoma ma- 
lignum. Decidualike cells 
are also found in the outer 
layers of the gestation sac, 
and one occasionally meets 
decidual masses on the peri- 
toneal covering of the tube. 
Here these decidualike struc- 
tures are furnished by pro- 
liferating peritoneal endo- 
thelium. 

Operations for ectopic 
pregnancy furnish excellent 
material for the study of the 
histology of the corpus lutem 
verum (Fig. 286). One is surprised to find occasionally that the ovary 
of the side on which the tubal pregnancy occurred does not show a 
corpus luteum verum but that the ovary of the opposite side contains 
this structure. This observation, not infrequently made by a number 
of workers on the subject, has given rise to the probably correct notion 
that tubal pregnancy is occasionally the result of an impregnated ovum 
wandering from one side to the opposite tube. Here the ovum becomes 
implanted before it can reach the uterus and gives rise in this manner 
to an ectopic gestation. 

Symptomatology. — The symptoms of ectopic pregnancy of course 
vary with its progress, according to the integrity of the sac, and to 
whether the foetus is living or dead. In the early period the ordi- 
nary signs of pregnancy are to be observed. Among these, cessation of 




Fig. 286.—" The corpus luteum verum."— Herzog. 



ECTOPIC PREGNANCY 661 

menstruation, nausea, and changes in the breasts are to be mentioned, 
though any and all of these symptoms may be absent, or modified by 
individual peculiarities. As a rule, however, menstruation is delayed 
or missed; and the patient exhibits sufficient of the classical symptoms 
of pregnancy to direct attention to the probability of such a condition. 
The recurrence of menstruation, which is usually irregular and pro- 
fuse, is a part of the early history of this condition; and the shedding 
of the decidua in the form of shreddy discharges, constitutes a valuable 
diagnostic symptom of the early period. 

The objective symptoms consist of an enlarged uterus with softened 
cervix simulating normal pregnancy, and with a soft and movable tu- 
mour upon one side of the uterus. A microscopic examination of the ex- 
pelled decidua will often disclose the character of that membrane posi- 
tively and thereby facilitate diagnosis. Prior to the rupture of the 
tube, the symptoms are obscure and uncertain and the physical signs 
are for the most part those of normal pregnancy. When rupture oc- 
curs (Fig. 287), which invariably happens by the end of the twelfth 
or fourteenth week, the sj-mptoms are marked and often most alarming. 
The pain is sharp and agonizing, and is referred to the pelvis. There 
is also a bloody flow from the 
uterus at this time. The pa- 
tient will usually exhibit the 
symptoms of profound shock 
and internal hemorrhage. It 
is not uncommon for the pa- 
tient to fall to the floor and 
suffer profound shock, and, 
in a large proportion of cases, 
fatal collapse from pain and 

hemorrhage will supervene Fig. 287.—" When rupture occurs ... the symp- 
within a few hours. In other toms are marked."— McMuktey. 

cases the symptoms will not be 

so severe and extreme. The rupture may be only partial and the hemor- 
rhage slight, when the symptoms will be correspondingly light and tran- 
sient. After a brief interval varying from a few hours to several days, 
the rupture will extend with renewed pain and pronounced symptoms of 
intra-abdominal hemorrhage. Associated with this condition will be gen- 
eral abdominal tenderness; followed later, if left alone, by symptoms of 
peritonitis. With primary intraperitoneal rupture there is hemorrhage, 
but the detection of effused blood inside the peritoneum is difficult and 
uncertain; hence in this condition bimanual examination will avail but 
little at first in detecting the effusion. Later, when the blood has gravi- 
tated and coagulated, the physical signs elicited by bimanual examina- 
tions will show the pelvis to be filled with a semisolid mass. 

When tubal abortion occurs, the symptoms may be of such limited 
severity as to deceive the patient and physician as to the nature of the 
illness. The ovum is detached from its bed in the ampullar extremity 




662 A TEXT-BOOK OF GYNECOLOGY 

of the tube and, with the accumulated blood of successive hemorrhages, 
forms a mass to become absorbed or to be walled off by adhesions. The 
general symptoms will be those of a tender, boggy mass and localized 
peritonitis, readily confounded with other forms of tubal disease. 
When rupture occurs with cleavage of the folds of the broad ligament, 
but without rupture into the general peritoneum, the symptoms are 
very obscure. The pain is paroxysmal, is prone to recur, and varies 
as to its severity. The symptoms of collapse are not so severe as when 
intraperitoneal rupture occurs, due to the limited hemorrhage — limited 
because of the resistance of the inclosing layers of the broad ligament. 
This is the form of ectopic pregnancy which permits continued vitality 
and development of the foetus. Secondary rupture takes place later 
into the peritoneal cavity, and may occur so soon after primary rupture 
that they can scarcely be distinguished. Few foetuses survive the 
fourth month, and the symptoms during these months result from the 
ruptures of the investing tissues, and the hemorrhages associated inevi- 
tably with these changes. After the fourth month, if the foetus sur- 
vives, the symptoms are those of intrauterine pregnancy with the modi- 
fications which would reasonably obtain under the altered environment 
of the growing foetus. 

Diagnosis. — From the above exposition of the symptoms of ectopic 
pregnancy, diagnosis will be approximately made in most cases before 
bimanual examination is utilized. When the history and symptoms are 
considered in conjunction with careful bimanual examination, the diag- 
nosis will, as a rule, be readily established. Diagnosis during the first 
week and prior to rupture is rarely practicable, not only on account of 
the vague and obscure character of the symptoms, but also from the 
fact that the symptoms are rarely sufficiently active to impel the patient 
to seek medical advice. Menstruation is absent or retarded during this 
stage, and hemorrhage coming on later marks the shedding of the de- 
cidua. Physical examination is of doubtful significance, as the unrup- 
tured tube may be displaced posteriorly or may recede from the exam- 
ining fingers as does a cystic ovary or hydrosalpinx. Under these cir- 
cumstances, the general symptoms of nausea and changes in the breasts 
and uterus will afford those presumptive indications upon which a 
tentative diagnosis will be made. When the primary intraperitoneal 
rupture takes place, the symptoms of severe localized pain, varying in 
degree with the extent of rupture, together with the indubitable signs 
of intraperitoneal hemorrhage, readily establish the diagnosis. This 
generally occurs about the seventh week and is usually the first positive 
symptom that impels the patient to seek advice. Ectopic pregnancy is 
most frequently observed in women with pre-existing pelvic disease, 
which fact renders slight menstrual disturbances of minor significance. 
A vaginal examination at the time of rupture is often negative on 
account of the presence of pain and muscular contraction. After the 
paroxysm of pain has passed, a mass on one side of the uterus will 
be apparent to the bimanual touch. The diagnosis, however, is deter- 



ECTOPIC PREGNANCY 663 

mined more by the distinct indications of hemorrhage than by the de- 
tection of a tumour. General abdominal tenderness is usually present 
with the symptoms of shock and collapse. 

When the rupture is into the fold of the broad ligament, the pain 
is more variable as to its severity and is usually paroxysmal. The 
shock is correspondingly less marked and the volume of effused blood 
is limited by the resistance of the peritoneal folds composing the broad 
ligament. "When the rupture occurs into the broad ligament very 
early in the period of pregnancy, the pain and hemorrhage may be 
very slight and may pass unrecognised as if the condition was one of 
ordinary menstrual pain or colic. Such cases often recover entirely 
without treatment, the ovum, secundines, and effused blood being ab- 
sorbed. When secondary rupture into the general peritoneal cavity 
occurs in this form of tubal pregnancy, there is a recurrence of pain, 
with the symptoms of hemorrhage and shock very similar in character 
and severity to primary intraperitoneal rupture. 

If the ovum survives after secondary rupture by retaining sufficient 
vascular attachment to the tubal mucous membrane for its support, an 
altogether different and more marked series of diagnostic indications 
makes its appearance. These advanced symptoms are marked after the 
fourth month and are both general and local. The general diagnostic 
symptoms are those characteristic of advanced pregnancy, and consist 
in absence of menstruation, changes in the breasts, vulva, and uterus, 
abdominal enlargement, movements of the foetus, placental souffle, and 
ballottement. Palpation of the foetus is easily made on account of the 
thinness of the abdominal walls. As a means of diagnosis, palpation is 
an untrustworthy resource in ectopic pregnancy, since the same impres- 
sions may be derived through the Avails of an attenuated uterus. Mc- 
Murtrv has had frequent cases of attenuation of the uterus (American 
Practitioner and News) in which repeated examination by several 
skilled observers gave the impression, in the face of a doubtful his- 
tory, of ectopic pregnancy nearing full term. Xormal delivery demon- 
strated the true condition to be that of attenuated uterus. In such 
cases the uterine walls are so thin that the foetal head, body, and limbs, 
may be followed by the hands, as if subcutaneous. In the diagnosis of 
all stages of ectopic pregnancy, the fact that intrauterine pregnancy 
may coexist should never be forgotten. 

When the term of pregnancy is completed (Fig. 288) and spurious 
labour supervenes, the diagnosis, if not previously made, will be estab- 
lished without special difficulty. The pains are well defined, contrac- 
tile, gradually increasing in duration and severity, recurring at inter- 
vals, and gradually subsiding. After spurious labour and the conse- 
quent death of the foetus, marked changes are observed in the foetal 
and maternal structures. The placental circulation continues for some 
time after the death of the foetus. The abdomen is usually decreased 
in size, foetal movements cease, and the uterus undergoes involution. 
In a certain proportion of cases, the gestation sac and foetus undergo 



664, 



A TEXT-BOOK OF GYNECOLOGY 



necrotic changes and break down into a gangrenous, suppurative mass. 
Hectic fever and general septic symptoms of severe type at once appear. 
After a severe and protracted illness, pus may find outlets, single or 
multiple, through the abdominal wall, rectum, vagina, or bladder, to 

be followed by the debris of 
the macerated foetus. In 
some instances, the foetus un- 
dergoes mummification, cal- 
cification, or is converted 
into a lithopsedion, so that 
the septic symptoms men- 
tioned may be modified or be 
altogether absent, in accord- 
ance with these varied meth- 
ods by which the foetus and 
secundines are managed by 
the digestive activity of the 
peritoneum. 

Treatment. — In the pre- 
antiseptic era of surgery, 
many methods of treatment 
were devised to arrest the de- 
velopment of the misplaced 
ovum and to promote its ab- 
sorption. Among these may 
be mentioned the administra- 
tion of strychnine to a toxic 
degree, hypodermic injections 
of ergot, and puncture of the 
cyst. More recently, the in- 
jection of morphine into the sac, and later the application of electricity, 
have been in vogue to destroy the foetus and to facilitate innocuous ab- 
sorption. All these methods of treatment are now obsolete, and proper 
surgical treatment is the only method deserving confidence. In no 
field of surgery have the results been more brilliant than in the treat- 
ment of ectopic pregnancy. A certain proportion of the cases of ectopic 
pregnancy in which rupture occurs during the early stages, recover 
without operation. Some present themselves to the gynecologist weeks 
or months after rupture, with the symptoms of pelvic inflammation of 
tubal origin. Abdominal section will reveal an old and infected blood 
clot, the removal of which will be followed by prompt recovery. These 
cases were formerly classified under the head of suppurating hemato- 
cele (Fig. 289). While recovery may eventually take place under ex- 
pectant methods of treatment, the larger proportion will be saved by 
prompt abdominal section and removal of the affected tube and its con- 
tents. In the following classes of cases, viz. — 1. Unruptured tubal 
pregnancy; 2. Cases of rupture without severe symptoms; 3. Cases of 




Fig. 288. — " When the term ... is completed . . . 
the diagnosis . . . will be established without 
special difficulty ." — McMurtky (page 663). 



ECTOPIC PREGNANCY 



665 



rupture with developing infection, Schauta has shown that the mor- 
tality of ectopic pregnancy, when uninterfered with, is over 65 per 
cent, while the mortality in cases treated by prompt surgical interven- 
tion is less than 6 per cent; from which it is apparent that the patient 
is exposed to greater peril by expectant treatment than by early resort 
to surgery. As heretofore stated, few cases of ectopic pregnancy will 
present themselves for treatment prior to the time of rupture, con- 
sequently it is exceptional that an opportunity is found for the simple 
and safe operation prac- 
ticable at this stage. The 
operation consists of ab- 
dominal section and re- 
moval of the involved tube 
in a patient free from 
shock or hemorrhage, and 
where the condition is un- 
complicated by inflamma- 
tory lesions. 

When rupture has oc- 
curred, especially if with 
extensive lesions directly 
into the general perito- 
neum, immediate opera- 
tion is a necessity to save 
life. The case is one of 
hemorrhage, and to arrest 
the bleeding is as impera- 
tive here as to secure the 
severed ends of a wounded 
blood vessel in other lo- 
calities. The operation 
in these cases is one of 
emergency, oftentimes to 
be done immediately upon 
seeing the .patient and 
recognising the condi- 
tion, with all the haste 
that is compatible with 

due regard to reasonable aseptic operative precautions. When the peri- 
toneum is incised through an abdominal incision, blood clots will present 
themselves through the incision. These must be rapidly turned out, 
the ruptured tube sought with the exploring fingers, and secured with 
a clamp. The hemorrhage having been arrested by this manoeuvre, 
the operator can deliberately ligate the ruptured tube at the uterine 
cornu, and cleanse the peritoneum of all fresh blood and clots. When 
primary rupture has preceded operation for a sufficient time, old and 
disintegrated blood clots will be found. Irrigation with hot saline solu- 




Fig. 289. — " These cases were formerly classified under 
the head of suppurating hematocele." — McMuktky 
(page 664). 



Q6Q A TEXT-BOOK OP GYNECOLOGY 

tion will subserve a double purpose in removing these clots, and, by 
rapid absorption through the peritoneum, in overcoming the associated 
shock and anaemia. During the progress of the operation in these 
cases, as well as prior and subsequently to that procedure, hypodermic 
medication and saline infusion should be applied to maintain the circu- 
lation. McMurtry has had the gratifying experience of witnessing the 
return of the pulse at the wrist under this treatment, when the patient 
seemed beyond surgical aid from the severity of the hemorrhage. The 
anaesthetic should be given barely to the point necessary for permitting 
the operation without pain, and should be laid aside at the earliest 
possible moment in order to avoid adding anything to the profound 
shock already existing. Ether is to be preferred in these cases on 
account of its stimulating effect. The question of drainage must be 
determined by the indications of individual cases. Where irrigation 
has been required, drainage for twenty-four hours by means of a glass 
tube will usually prove advantageous, and will also give assurance as 
to hemostasis. When the patient is placed in bed, dry heat should be 
applied and the foot of the bed elevated. When a patient has passed 
safely the immediate danger from rupture, with the pelvis filled with 
blood clots and membranes undergoing septic changes and suppuration, 
it may be best, if she has become feeble from sepsis, to incise the fornix 
vaginae and remove disorganized clots and septic foci, thereby pro- 
viding an outlet and securing drainage. In all other conditions, the 
surgical requirements of ectopic pregnancy will be best subserved by 
abdominal section rather than by vaginal incision. 

The operative treatment in advanced ectopic pregnancy will vary 
as the foetus is living or dead, and according to the consequent state of 
the placental circulation. The placental site varies in these cases, 
and may be on the abdominal wall, in the uterus, or spread out most 
frequently over the broad ligament and uterus; in some cases it is 
also attached to intestinal and bladder surfaces. After spurious labour 
and the death of the foetus, the placental circulation remains active 
for some time. Hence, under these circumstances it is best to defer 
operation for several weeks in order that the placental thrombi may be- 
come organized. Then the placenta can be enucleated without serious 
danger from uncontrollable haemorrhage. The danger to life in those 
cases where the pregnancy has advanced beyond the fifth month, and 
especially in those that have gone beyond full term, is extreme. The 
difficulty centres about the removal of the placenta. When the placenta 
is spread out over the uterus and intestines and the circulation through 
it is active, a fatal hemorrhage will usually follow any attempt at its re- 
moval. If this condition is found to exist, the cord is tied and cut 
short after removal of the foetus, and the sac is stitched to the edges 
of the incision after packing it with gauze which is allowed to protrude 
from the lower angle of the incision. The danger here, too, is great; 
for the large mass is readily infected, and secondary hemorrhage will 
often ensue as the placenta breaks down. When the foetus is alive 



ECTOPIC PREGNANCY 



667 



and viable, operation should be done without waiting for the comple- 
tion of the full term of pregnancy and spurious labour. In opening 
the abdomen, the sac should be avoided carefully by diverting the line 




Fig. 290. — " ... A patient who had gone two months beyond terra, maceration of the foetus 
having commenced." — McMurtry (page 668). 



of incision. When the sac is opened, the child is extracted and handed 
to an assistant. If the placenta is favourably situated, it may be 
rapidly enucleated and the hemorrhage controlled by firm gauze pack- 



668 A TEXT-BOOK OF GYNECOLOGY 

ing. Otherwise, it may be best to leave the placenta as already de- 
scribed. 

When the foetus has been dead for several weeks, the dangers of 
operation are much lessened. In these cases it will often be practicable 
to remove the placenta at once without severe hemorrhage. When 
the foetus has been long dead and has undergone mummification, adi- 
pocere change, or calcification, the operative procedure for its removal 













a§ -. 










^ ^Jfj 


kg 


flWf <aW 






10. " Wfla^^^^l- Y 




jf^~?^(B(B| 


^^^\ 




/ I 






•:J 






} 'h \ 






WlllifWillS 





Fig. 291. — " The child was removed by abdominal section." — McMurtry. 

will present no additional difficulties, and can be conducted in accord- 
ance with the principle already set forth in this chapter. Eeed operated 
on a patient at the Cincinnati Hospital who had gone two months be- 
yond term, maceration of the foetus having commenced (Fig. 290). The 
child was removed by abdominal section (Fig. 291) and the sac sutured 
to the margins of the wound and packed with gauze, as the slightest 
traction on the placenta induced haemorrhage. The placenta was sub- 
sequently removed, and the patient made a complete recovery. 



CHAPTER XLIII 

NEOPLASMS OF THE BROAD LIGAMENT 

The broad ligament — Varieties of neoplasms — Cysts (parovarian), origin, causes, 
symptoms, complications, diagnosis, treatment — Hydrocele of the round liga- 
ment — Fibroma, myoma, and lipoma; symptoms, diagnosis, treatment — Der- 
moids — Solid tumours of the round ligament — Pelvic varicocele — Aneurismal 
varix and phleboliths — Malignant neoplasms : Carcinoma ; sarcoma. 

The broad ligaments consist of folds of peritoneum, extending 
from the uterus to the bony wall upon either side of the pelvis. On 
the upper margin of each of these peritoneal folds, and extending 
lengthwise with it, is the Fallopian tube, the fold beneath it being fre- 
quently designated the mesosalpinx. Attached to the posterior fold 
of the broad ligament, near its outer extremity, is the ovary. There 
are various structures contained within and beneath the folds of the 
broad ligament. It is necessary in this connection to consider only 

(a) the round ligament, which extends from the uterus to the inguinal 
ring, and over which there drops a sort of duplication of the peri- 
toneum, usually designated the anterior fold of the broad ligament; 

(b) the parovarium, or the rudimentary survivor of the Wolffian 
body; (c) the Mood vessels; (d) the lymphatics; and (e) unstriped 
muscular fibres. Each of these several structures may present patho- 
logic changes demanding consideration. 

Neoplasms developing within the broad ligament may originate 
from any of the structures therein contained. They may be consid- 
ered under the two classes of (a) benign, and (b) malignant. 

Benign enlargements, some of which are not, strictly speaking, of 
neoplastic character, but which, for convenience, are grouped together 
in this chapter, are : 

1. Cysts arising from the inner tubules of the parovarium. 

2. Fibromata arising from the fibrous connective tissue. 

3. Myoma t a arising from the unstriped muscular fibres. 

4. Fibromyomata arising from the two preceding. 

5. Lipomata arising from the areolar tissue. 

6. Dermoids arising from the connective tissue. 

7. Varicocele arising from the dilated veins. 

8. Aneurismal varix arising from the increased number and en- 
largement of blood vessels. 

669 



670 A TEXT-BOOK OF GYNECOLOGY 

9. Phleboliths arising from the calcareous infiltration of thrombi. 

10. Hydrocele arising from the round ligament. 

Malignant Neoplasms : 

1. Carcinomata / ln -, -. ., 

~ , > are generally secondary deposits. 

Cysts developing 1 in the broad ligament may arise from (a) the 
epoophoron (parovarium), (b) the paroophoron, (c) the round liga- 
ment (hydrocele). It is important as a preliminary step in this con- 
nection to consider more in detail these various structures — particu- 
larly the two former. 

Notwithstanding that M. Sanger, W. Fischel and Werth (Archiv 
fur Gynakologie, Bd. xv, xvi) wrote in 1880 extensively, clearly, and 
correctly, upon the tumours of the broad ligament and of the struc- 
tures lying between its folds, Doran ( Tumours of the Ovary and Broad 
Ligament, 1885) expressed regret that the gynecologists manifested so 
little interest in the parovarium. Since then, however, most of the 
writers on gynecology, and the text-books on this subject, speak more 
or less extensively of this organ and its relation to certain pathologic 
conditions. While, clinically, the diseases of the parovarium and the 
mesosalpinx can not, or should not, be considered separate or distinct 
from those of the ovary, they are, nevertheless, peculiar to organs 
that are as different from the ovary as is the Fallopian tube; and 
just as the tubes, and the affections characteristic of them, are dealt 
with by themselves, so should the diseases of the parovarium and its 
peritoneal coverings be treated distinctively and form a chapter of 
their own. 

Parovarium is the term first used by Kobelt. Waldeyer called it 
epobphoron, in contradistinction to the paroophoron (which lies closer 
to the uterus and represents the vestiges of the corpus Geraldes of the 
male, the parepididymis). The organ was formerly, and still is, quite 
generally known also as the corpus Kosenmuller because Eosenmiiller 
gave the first description of it. The mesosalpinx is merely a part of the 
broad ligament. The two terms should not be used synonymously. 

Briefly defined, the parovarium is that portion of the female inter- 
nal genitalia which represents the atrophic or rudimentary remnant of 
that part of the Wolffian body that would have become the epididymis 
in the male. 

Anatomy (Embryology). — The parovarium (Fig. 207) resides be- 
tween the two folds of the broad ligament, and consists of a number 
of small, " closed " tubules running transversely in a fan-shaped ar- 
rangement from the ovary toward the Fallopian tube. These tubules 
can be easily detected by the unaided eye, if the normal meso- 
salpinx is spread out and held up against the light (Quain). The 
number of tubules varies, as a rule, from 10 to 15, though there may 
be only half a dozen, or as many as 25 or 30 (H. C. Coe). It is said 
that they have no openings ; that they measure from a little less than 
0.5 millimetre to 1 millimetre in diameter; that their walls are 0.05 



NEOPLASMS OF THE BROAD LIGAMENT 671 

millimetre in thickness, and consist of an external annular membrane, 
and an internal membrane of longitudinal fibres (Olshausen), lined 
with cuboidal or low cylindrical, and sometimes ciliated, epithelium; 
and that they are surrounded by several layers of spindle cells, appar- 
ently nonstriped muscular fibres (H. A. Kelly). The longest and 
largest of these tubules, which is the remnant of the Wolffian duct, 
runs parallel to the Fallopian tube along the base of the fan formed 
by the rest, and then extends to the side of the uterus and becomes 
lost in the vaginal wall. According to Olshausen, the scanty con- 
tents of these tubes coagulate on the addition of acetic acid. In some 
of the lower animals, the sow for instance, the Wolffian duct persists 
and is known as the duct of Gartner. Occasionally, traces of this 
duct may be seen in the human female upon cross section of the 
cervix or body of the uterus. Those of the vertical tubules termi- 
nating near the outer margin of the broad ligament are, by some au- 
thors, called Kobelt's tubes, and it is at their extremities that, very 
often, small transparent cysts develop, the so-called hydatids of 
Morgagni. 

The origin of cysts developing in the broad ligament is, principally, 
from the epoophoron (parovarium). Occasionally, though rarely, 
cysts may arise from the paroophoron, which lies close to the uterus. 
When small, we can distinguish between them only by their location, 
the former occupying the outer and upper, the latter the inner and 
lower, portion of the broad ligament; when large, whether peduncu- 
lated and extending into the peritoneal cavity or subserous, their 
origin can not be positively determined. 

The parovarian cystoma (Fischel, Archiv fur Gynakologie, Bd. xv, 
pp. 214, 215) is the result of a cystic degeneration of that part of 
the parovarium which not only extends into the hilum of the ovary, 
but is found where Pniiger's loops begin to have granulosa-epithe- 
lium, and that is within the cortical layer of the ovary itself. The 
ovarian tissue, during the development of these tumours, either atro- 
phies or participates in the formation of the same. These growths 
have the same physical characteristics as those that form from the 
epoophoron and paroophoron respectively, because they are in reality 
of parovarian' origin. They, too, remain intraligamentary ; but fre- 
quently become pedunculated and differ from the rest only in contain- 
ing ovarian tissue, which, however, can not always be found. 

History. — Up to 1865, little or nothing was known of broad-liga- 
ment cysts. It is through the observations and reports of cases by 
Prochownik, Schroder, Olshausen, Spiegelberg, ' Gusserow, and others, 
that we know something definite concerning these neoplasms. But to 
Wilhelm, Fischel and Olshausen (1880) belongs the credit of first de- 
scribing minutely, macroscopically and microscopically, their structure 
and relations, which, as will be seen, are of no little importance. 

The frequency of their occurrence has never been rightly estimated. 
Formerly, they were considered ■quite rare. It is now well known that 



672 A TEXT-BOOK OF GYNECOLOGY 

they are much more frequent than is ordinarily supposed. While they 
are met with less often than ovarian cysts, it must not be forgotten 
that many a cyst has been diagnosticated as belonging to the ovary, 
which, in truth, was parovarian in its origin. 

Cysts of the broad ligament may develop at any time of life, but 
more especially after the period of puberty. Olshausen's youngest 
patient was fifteen, Kelly's oldest, seventy-three years of age. As a 
rule, they are monocysts, and vary in size from 1 centimetre to 40 
centimetres in diameter. The small cysts connected with, or spring- 
ing from, Kobelt's tubes usually remain small, and do not give rise 
to any symptoms. Both broad ligaments may be affected with one or 
several cysts at the same time; or one cyst may so develop as to oc- 
cupy both ligaments in course of time. 

Every parovarian cyst is, necessarily, intraligamentary. In a cer- 
tain sense they remain so; notwithstanding that, in one case, they 
may grow into the peritoneal cavity and become more or less pedun- 
culated, and that, in the other, the direction of growth is toward the 
pelvic floor and retroperitoneal space. In the latter case, the tumour 
spreads the leaves of the ligament or ligaments apart and becomes, to 
a great extent if not entirely, subserous in its location. Again, the 
tumour may dissect up the parietal peritoneum anteriorly and poste- 
riorly, or both. Their conduct in this respect is like that of the solid 
tumours of the broad ligament already described. In consequence of 
the varying distribution of the parovarian cysts and cystomata, they 
vary in shape and give rise to different symptoms at a certain period 
of their existence. Those cysts which develop in the direction of the 
abdominal cavity will have more or less of a pedicle (when the base 
of the ligament is not taken up, a pedicle may be often formed by 
traction upon the tumour during the operation), will be perfectly oval 
in shape, and covered with peritoneum in every part. Those cysts 
that grow downwardly, separating the two layers of the broad liga- 
ment, become to a great extent irregular in outline, are covered by 
peritoneum in part only, and, of course, have no pedicle. 

Parovarian cysts are, then, either entirely or in part, covered with 
peritoneum derived from the broad ligament. The outer surface of 
the cyst or cystoma is, therefore, smooth, and immediately beneath 
it can be seen the blood vessels running in every direction. The tube 
and its fimbriated extremity are very much stretched, and extend over 
the upper and posterior surface of the tumour to which they are loose- 
ly, sometimes firmly, adherent (Fig. 292). The fimbriae, especially 
the fimbria ovarica, are spread open and very much elongated. The 
tube, as a rule, continues patulous and unchanged in its structure. 
The ovary, often perfectly normal, may be found suspended from, or 
flatly attached to, the lower and posterior surface of the growth. 
When the ovary can not be found, it may be atrophied and lost in, or 
become part and parcel of, the tumour itself. The latter event occurs, 
according to Fischel, in the ovarian cystomata of parovarian origin. 



NEOPLASMS OF THE BROAD LIGAMENT 



673 



The cyst wall is made up of peritoneum, glandular, muscular 
(smooth), and connective tissues. Its inner surface is lined with cil- 
iated epithelium (Fig. 293), either alone, or in connection with the 




Fig. 292.—" The tube and its fimbriated extremity are very much stretched, and extend over 
the upper and posterior surface of the tumour.'" — Zinke (page 672 |. 

cylindrical variety. The thickness of the wall varies, usually from 
0.3 to 3.5 millimetres, although, at times, it may be much thinner or 
thicker; but it is nearly always uniform and seldom shows transpar- 
ent patches. Its inner surface is corrugated, and not infrequently 
studded extensively with papillary formations. The corrugation 
Fischel believes to be due to the presence of muscular fibres in the 
cyst wall; Olshausen and 
others, however, do not 
agree with him. The 
smooth muscular fibres 
are found nearer the 
outer surface of the Avail 
and run in every possible 
direction; they may be 
absent in spots. 

The glands found bv 

_. ° J iiG. 293 (Pfannexstiel). — "Its inner surface is lined 

-bischel, which he states with ciliated e P itheiium.»-ZiN KE . 

are lined with a low 

cylindrical epithelium, can not always be detected. Olshausen be- 
lieves that both glands and papillary formation are more generally 
absent than present. 

The fluid contents of the sac, too, vary much in colour, consistence, 
and specific gravity. This depends, mostly if not always, upon the 
44 




674 A TEXT-BOOK OF GYNECOLOGY 

age and size of the tumour and the amount of blood that, from time 
to time, may escape into it in consequence of occasional rupture of 
blood vessels, the result of torsion of the pedicle, distention or punc- 
ture of the cyst wall, or external injuries. In by far the great ma- 
jority of the small and medium-sized tumours, the fluid is clear and 
limpid like water, sometimes of a yellowish tinge, sometimes opales- 
cent, and contains little or no albumin. The specific gravity is exceed- 
ingly low, 1002 to 1004. Under these conditions, too, the cyst wall 
is often flaccid. When the cyst is old and large, the fluid is likely to 
be thick, much darker in colour (greenish brown or black), and may 
contain considerable albumin and have a high specific gravity, 1022 
as in Schatz's case. Sometimes blood coagula, old and of recent 
date, may be discharged from the cyst when opened. Spiegelberg says 
that the parovarian cysts may also contain " paralbumin, granular 
debris, decolourized and shrivelled red blood corpuscles, scattered white 
corpuscles, large granular fat cells, and plates of cholesterin." 

Causes. — The causes of intraligamentary cysts and parovarian 
cystomata are very obscure. Indeed, we must admit that we do not 
know. The following are merely of a speculative nature : Menstrual 
congestion; hereditary predisposition; chlorosis during puberty 
(Scanzoni). Irritation, as from displaced or diseased pelvic organs 
and other sources, may be admitted as a probable cause. Olshausen 
states that they are rare in childhood; that no period of life is ex- 
empt, and that they are often associated with ovarian disease of the 
same or the opposite side. 

Symptoms, Complications, and Diagnosis. — These may best be con- 
sidered under one head. Partly and completely pedunculated parova- 
rian cysts, or cystomata free from all complications, may not give 
rise to any symptom whatever, except when they assume great propor- 
tions; and then the symptoms may be limited to enlargement of the 
abdomen, dyspnoea, dulness, and distinct fluctuation on percussion. 
It is different when there is no pedicle and cysts develop, in part or 
entirely subserously. Pelvic discomfort and occasional pains may be 
present early, and may gradually increase in frequency and duration 
as the tumour grows and dissects up the pelvic and parietal perito- 
neum, and displaces the viscera concerned. Advice is sought early and 
examination usually permitted. Inspection of the abdomen may reveal 
some enlargement; percussion, some dulness in the lower part of the 
abdomen; and bimanual examination, a fluctuating swelling with up- 
ward, downward, anterior, posterior, or lateral, displacement of the 
uterus and some of its appendages. Here, too, there will be noticed a 
steady augmentation of the symptoms. The bladder will become dis- 
turbed in its position and this may cause frequent, painful micturi- 
tion or even incontinence of urine. The rectum may be affected in 
the same way. The symptoms, then, in all uncomplicated cases, will 
vary according to the size, age and locality, of cysts. As they are of 
very slow growth and sometimes stationary, other conditions may give 



NEOPLASMS OF THE BROAD LIGAMENT 675 

rise to complications, as, for instance, pregnancy, rupture of the cyst, 
torsion of the pedicle, diseases of the uterus and its appendages, etc. 
The physician may be consulted for any one of these or for several of 
them, and may discover the presence of a parovarian tumour by 
accident rather than otherwise, either by his examination, or while 
operating in the abdominal cavity for other diseases or injuries. It is 
evident, therefore, that the diagnosis is not always easy, and that 
errors may be made; but let it be remembered that fluctuation is 
nearly always very distinct and superficial, as in ascites, and that, if 
the cyst wall is flaccid, the percussion note may change slightly with 
the change in posture of the patient. If a spontaneous rupture takes 
place, there may be no symptoms. This, it is said, may happen re- 
peatedly, without even a suspicion on the part of the patient, and may 
be eventually followed by recovery. Rupture of the cyst, spontane- 
ously or accidentally, is always followed by diuresis; often, it is also 
followed by pain, in the absence of complications ; and always by pain, 
sometimes by shock, and occasionally by sepsis and death, if this acci- 
dent occurs in the presence of acute or chronic inflammatory suppura- 
tive complications. That there are cases in which a diagnosis can be 
made, can not be doubted. When we find a flaccid abdominal tumour, 
with distinct fluctuation and devoid of hard nodules, which is of slow 
growth, accompanied by a hstory of the absence of pain, and, possibly, 
of repeated rupture without serious consequences, it seems safe to 
conclude that we are dealing with a broad-ligament cyst. But it may be 
wise not to be too positive even then. At the present high stage of devel- 
opment of abdominal and pelvic surgery, puncture of any cystic growth 
for diagnostitial purposes must be mentioned only to be condemned. 

To distinguish between a papillary parovarian cystoma and a mul- 
tilocular cyst of the ovary, we need only remember that the former is 
mostly, if not always, bilateral; that it is always intraligamentary, 
and that the inner surface of the cyst is lined by ciliated epithelium. 

Treatment. — The treatment of parovarian and other cysts of the 
broad ligament is very much like that of the solid tumours of this 
structure. Formerly, puncture of the cyst was earnestly advised, and 
is still held out, by some, as worthy of trial now. Zinke can not sub- 
scribe to this view. It may be true, though he is inclined to doubt it, 
that some patients have been cured by this means. He does not 
doubt that hundreds of women afflicted with these growths have each 
been successfully tapped many times, and, in some instances, hun- 
dreds of times ; but he knows, also, from personal experience and the 
experience of others, that in the great majority of all the cases so 
treated, nearly all were but temporarily relieved and eventually died 
of exhaustion. In some, adhesions were caused that subsequently 
complicated the extirpation of the growth; and in others, conditions 
were established that resulted in the death of the patient, as the result 
either of carelessness or of errors in diagnosis. There is no class of 
cases that, when free from complications, recover more promptly from 



WQ A TEXT-BOOK OF GYNECOLOGY 

radical operative procedures when done under strictly aseptic precau- 
tions than these. The pedunculated variety, especially, admits of 
easy removal of even very large tumours and through a very small 
incision. Those cases which develop within the broad ligament with- 
out a pedicle, are often shelled out with ease, and not unfrequently 
a pedicle may be made of a part of the base of the broad ligament 
not taken up by the cyst, and of a part which is stripped from the lat- 
ter during its enucleation. In the class of cases that are entirely sub- 
serous or extraperitoneal, as in the solid tumours of the broad liga- 
ment, enucleation of the entire cyst may be accomplished and the 
cavity left treated in the same way as recommended under Treatment 
of Solid Intraligamentary Tumours. 

Should the removal or enucleation of a cyst seem, for any reason, 
impossible, or, on account of existing complications, inadvisable, then 
the plan of removing part of the cyst and stitching the edge of the 
remaining portion to the abdominal wound for the purpose of packing 
and drainage, as first advised by Spencer Wells, and practised by Ols- 
hausen, Winckel, Sanger and others, may be resorted to, and complete 
recovery confidently expected. Some of our German confreres, also, 
state that, in the absence of complications, the sewing of the remain- 
ing portion of the sac, as just described, is really unnecessary ; because 
its contents and what may be subsequently secreted, will be readily 
absorbed by the peritoneum; the sac eventually shrivels up, atro- 
phies, and the patients recover perfectly and permanently. 

An important innovation in the technique of operations for intra- 
ligamentary cysts, was devised almost coincidently, and with equal 
originality, by Hall of Cincinnati and Hawkins of Denver. The 
method, which is essentially a supravaginal hysterectomy, is described 
by Hall as follows: 

" Open the abdominal cavity in the usual manner. Then, tap the 
cyst and empty it. Next, ligate the ovarian artery on the tumour side 
at the pelvic border. Ligate the ovarian artery on the opposite side, 
outside the ovary if that organ is to be removed, inside it, if it is 
to be left. Divide the peritoneum crosswise above the top of the 
bladder and push the bladder down. Ligate the uterine artery on the 
healthy side. Cut across the cervix, and clamp or ligate the uterine 
artery on the tumour side. The blood supply is then cut off and the 
patient has not lost a drachm of blood. The capsule of the tumour 
can now be divided at a suitable point behind and in front, and the 
tumour can be enucleated from below upward with much greater ease 
than from above downward, and with corresponding safety to the 
ureter, the rectum, and the iliac vessels. Close the peritoneum over 
the pelvic floor with running sutures of catgut. Every part of the field 
of operation is in view of the operator." The drawing (Fig. 294) from 
a specimen of Hall's, shows the extent of the operation. 

This operation, which certainly offers the maximum of safety to 
the patient, is one that necessarily involves the loss of the reproductive 



NEOPLASMS OF THE BROAD LIGAMENT 



677 




Fig. 294. — "A specimen of Hall's" (intraligamentary 
cyst). — Reed (page 676). 



power. This may be a matter of serious moment in certain cases, and 
should not, therefore, be done, except after the menopause, or when 
fecundity has been destroyed by disease; or as a matter of emergency, 
and even then as a matter of policy it is better to have the consent 
of the patient. Intraligamentary cysts may be removed by enucleation 
without damage or conse- 
quence to the reproduc- 
tive apparatus, although 
this is manifestly more 
hazardous to the patient 
than is the Hall-Hawkins 
operation. 

Hydrocele of the 
round ligament may de- 
velop precisely as does 
hydrocele of the sper- 
matic cord in the male. 
The pathology is essen- 
tially the same in the two 
conditions, with the ex- 
ception that, in women, 
the dropsical accumula- 
tion is much more re- 
stricted, being as a rule 

limited to the canal of Nuck; the sac may present at the inguinal 
ring, or even protrude beyond it, as a fluctuating tumour, suggestive 
of a hernia with a fusion. It is not ordinarily a painful affec- 
tion, although it may occasion enough disturbance to attract atten- 
tion to it, when the exact character of the difficulty may be ascertained. 
Treatment may consist of (a) puncture, followed by different varieties 
of injections; (b) free incision of the sac, followed by sterilized tam- 
ponade; or, (c) extirpation of the sac. The two former methods are 
painful, tedious, and uncertain — the last-named, alone, being entitled 
to the designation of radical. Yolbrecht operates upon hydrocele of 
the round ligament, when the sac is large and located high up, by 
making a section of the inguinal canal in its entire length. The sac 
is then isolated and cut away, a ligature being placed upon the pedicle; 
the canal is then sutured, layer to layer, as in the Bacini operation. 

Fibroma, Myoma, and Lipoma of the Broad Ligament. — Fibroma 
and myoma may develop in the broad ligament as such pure and simple, 
or combined (fioromyoma). They are subject to cystic degeneration 
in this as well as in other regions of the body (cystoftbroma or cysto- 
myoma). The myoma of the broad ligament is the leiomyoma of 
Ziegler, because it is made up principally of newly developed, un- 
striped muscular fibres. Prior to 1880, the primary development of 
these tumours in the broad ligament was almost universally denied. 

To M. Sanger (Archiv fur Gynakologie, Bd. xvi, 1880, s. 258) be- 



678 A TEXT-BOOK OF GYNECOLOGY 

longs the credit of establishing a definite clinical autonomy for this 
variety of intraligamentary neoplasms. He states that Klob, in 1864, 
questioned the possibility of the independent development of the 
same; though Kivisch, in 1849, admitted the primary formation of 
small fibroids, but when he saw large ones, they, in his opinion, could 
only arise from the uterus. Scanzoni (1875) was of the same opinion; 
he attributed their origin to small blood extravasations. Even 
Schroder (1879) denies that fibroma and myoma have their genesis 
in the broad ligament, notwithstanding that Virchow recognised their 
primary development in this locality, and Schetelig (Archiv fur Gynd- 
kologie, Bd. i, s. 459) had described a large " cystomyoma teleangeiectodes 
cavernoswn of the right broad ligament," which showed its genuine 
developmental origin to be from the unstriped muscular fibres of the 
same. Sanger then quotes the cases of Schmidt (Prager medicinische 
Wochenschrift, 1878, s. 35) and Mikulicz (Wiener medizinische Wochen- 
schrift, 1878, s. 19-21). That of the former was a case of fibrosarcoma 
weighing 8 kilogrammes (17.60 pounds); it sprang from the right 
broad ligament, had a long, tolerably thick pedicle, and occurred in 
a patient thirty-three years old. The latter was an oedematous fibro- 
myoma weighing 5 kilogrammes (11 pounds), and developed in the left 
broad ligament of a nullipara aged twenty-two years, and single. The 
latter tumour was of slow growth, was complicated with ascites, and 
had a very thin pedicle. Both patients recovered. 

It is interesting to note that even Professor Winckel, so late as 
1887, still clung to the idea that myomata of the broad ligament were 
at first, probably, subserous or intraparietal, and grew from the 
uterus into the broad ligament; he admits, however, that primary 
growths have been observed. There is no reference at all to intra- 
ligamentary fibroma and myoma in Mann's American System of Gyne- 
cology, 1888. The same must be said of Thomas and Munde's Prac- 
tical Treatise on the Diseases of Women, 1891. Senn, in his book on the 
Pathology and Surgical Treatment of Tumours, 1895, p. 511, speaks of 
the primary formation of myofibromata within the broad ligament, but 
still maintains that " not infrequently " they originate from the uterus. 
Kelly (Operative Gynecology, 1898) no longer discusses the question, and 
describes and illustrates a variety of cases. A beautiful representation 
of a cystic myoma can be found on p. 394, vol. ii, of his work. 
Baldy (American Text-booh of Gynecology) devotes not quite one page 
to the consideration of intraligamentary fibroids, and calls them " ex- 
ceedingly puzzling." Zinke states that Edwin Ricketts presented 3 
cases of intraligamentary fibroids to the Academy of Medicine of Cin- 
cinnati, Ohio, weighing severally 16, 8, and 65 pounds. They were re- 
moved from patients aged forty-four, fifty-one, and forty-eight years 
respectively. The last died; the two former recovered. 

Zinke also maintains that at this time it is simply impossible to 
estimate the frequency of these growths. They are rare; but they do 
occur sufficiently often to demand the full attention of every gyne- 



NEOPLASMS OF THE BROAD LIGAMENT 679 

cologist and abdominal surgeon. According to Rosenwasser (Annals 
of Gynecology and Pediatry, vol. iv, No. 6, 1891) — 

Olshausen found among 280 ovariotomies 20 intraligamentary 
Wylie " " 500 " 6 

Munde " " 154 " 18 

Rosenwasser " "12 " 6 " 

or " 946 '■ 50 " = 18.85 per cent. 

Sanger (1880) remarks: "I have the conviction that our experi- 
ence with solid tumours of the broad ligament will be like that with 
parovarian cysts. At one time believed to be great rarities and prac- 
tically unimportant, they have been observed so frequently that every 
laparotomist must take them into account." 

The only references Zinke can find to lipomata of the broad liga- 
ment are contained in Pozzi's Treatise on Gynecology, p. 187; in Senn's 
Pathology and Treatment of Tumours, p. 407, which is merely a quota- 
tion of the former; and in Winckel's Diseases of Women, p. 598. Pozzi 
saw one case that had been mistaken for an ovarian cyst. An explora- 
tory puncture was made, and the patient died of embolus three days 
later. Terrillon is cited by Pozzi as removing a lipoma springing from 
the mesentery and weighing 60 pounds. Winckel quotes Pernice, who 
extirpated one weighing 30 pounds from the right broad ligament; 
his patient, aged sixty-four years, recovered. Winckel also gives credit 
to Klob and Orth as having seen similar cases. After quoting Rokitan- 
sky, who observed a lipoma the size of a walnut on the lower border 
of the tube in a woman aged forty-seven years, Winckel dismisses the 
subject by saying that " lipomata have no practical significance be- 
cause of their small size." 

The clinical character, symptoms and diagnosis of solid tumours of 
the broad ligament are much the same as those produced by the cysto- 
mata of this region. They are of slow growth, not tender to the touch, 
and are with or without pedicle. When pedunculated, as in Dr. 
Schmid's case, they extend freely into the general peritoneal cavity 
and admit of comparatively easy removal; when there is no pedicle, 
the tumour, develops subperitoneally, spreading the folds of the broad 
ligament apart and forcing the uterus to one or the other side. Like 
some of the parovarian cysts, these tumours may dissect up the parietal 
peritoneum anteriorly or posteriorly or both, and thus present great 
difficulties during efforts at their removal. The diagnosis is by no 
means easily made, and, so far as Zinke is able to determine, in the 
great majority of the cases observed, it is arrived at only after the 
abdomen has been opened. This, too, is his own individual experience 
with these cases. 

The treatment of the solid but benign tumours of the broad ligament 
may be conveniently divided into palliative and curative. Both 
methods of procedure are much the same as those in vogue for uterine 
fibroma and myoma, and the reader is referred for the details of descrip- 



680 A TEXT-BOOK OP GYNECOLOGY 

tion to the chapter on this subject in this work. Suffice it to state here, 
that the use of ergot, hydrastis canadensis, and electricity, have been 
well tried by good, earnest, well-trained men. The results are anything 
but satisfactory so far as a cure or decided relief is concerned. Apostoli, 
Keith, Engelmann, and many other able and painstaking investigators 
of the value of electricity in these cases, have been disappointed in 
the results obtained, and it is pretty generally believed that the so- 
called " cures " accomplished, about 2.4 per cent of many hundreds of 
cases, represent the possible percentage of errors in diagnosis {American 
Text-look of Gynecology, p. 401). Unfortunately, the result obtained 
with ergot, hydrastis canadensis, and iodide of potassium, hypoder- 
matically or per os, is not much better. Zinke, for a number of years, 
has given these remedies a faithful and extensive trial, even after 
spending a month with Apostoli in Paris and many years of association 
as pupil and assistant to C. D. Palmer, who was, and to some extent 
still is, a firm believer in and ardent advocate of these methods of 
treatment. If there is any doubt as to the value of any of these 
means in the treatment of uterine fibroma and myoma, it would seem 
that the outlook is not very encouraging with the same measures in 
the treatment of intraligamentary fibromyomata. There appears to be 
no record of the application of the above treatment in lipomata of the 
broad ligament. 

The only true remedy is removal of the tumour or tumours by 
enucleation through the abdomen; although Pean, and a few others 
who have followed his method of morcellement, have done so success- 
fully, by accident rather than otherwise, by the vaginal route. 

According to Olshausen the credit of first presenting and recom- 
mending the essential features of the present mode of enucleating these 
growths belongs to Miner, of Boston (1869). The operation of enuclea- 
tion is not a very difficult one if the tumour is not large, and has 
grown toward the abdominal cavity rather than into the pelvis; but 
when excessive in size, both the abdominal and pelvic cavities will be 
occupied by the tumour. Again a tumour or tumours of but moderate 
dimensions may be so situated in the pelvis as to fill it out completely, 
thus displacing the pelvic viscera upward in every direction; in addi- 
tion to this, there may be numerous adhesions and other complicating 
diseases, which will make the operation very difficult and formidable. 
Martin, Hegar, Kaltenbach, Olshausen, Kelly, Baldy, and many 
others, have clearly described how to proceed under the various con- 
ditions that may present themselves. The principal object to be at- 
tained is to avoid hemorrhage and injury to other structures as much 
as possible. The ureters, bladder, and the large blood vessels within 
the pelvis, are especially endangered when the growth is very large 
or confined to the pelvis, and the adhesions numerous and firm. Pe- 
dunculated, solid, intraligamentary tumours, are very rare. Their 
removal is simple enough. The stitching up of the cavity left by the 
peritoneal folds after enucleation of the tumour is no longer prac- 



NEOPLASMS OF THE BROAD LIGAMENT 681 

tised. Where the folds fall into apposition, there is no need for sewing; 
where they remain separate, experience has shown that recovery is much 
more prompt when, after arrest of hemorrhage, the cavity is simply 
cleaned and the abdominal wound closed without drainage. Martin, 
Hegar, and Kaltenbach recommended drainage into the vagina. Greig 
Smith, Goodell, and Skene were the first to abandon it. At present, 
drainage in these cases is, with most operators, a thing of the past. 
We doubt whether Senn, who recommended vaginal drainage in his 
book on tumours (1895), still practises what he then taught. Ols- 
hausen (1886) does not approve of supravaginal hysterectomy in all 
these cases, as has been advocated by Eeuss, Goffe, Schenk, Braun, 
Kelly, Hall, and others. Olshausen believes that this procedure simply 
complicates and prolongs the operation, and should not be resorted to 
unless there is an absolute necessity for it. (See Treatment of Par- 
ovarian Cysts.) 

Dermoid tumours of the broad ligament may develop from the 
underlying connective tissue. Quervain (Archiv fur Jclinische Chi- 
rurgie, Bd. lvii, H. 1), in mentioning this fact, alludes to 15 cases of 
dermoid tumours developing from the pelvic connective tissue. The 
symptoms in such cases are due to pressure. Dermoids in front of 
the rectum may simulate tumours of the cul-de-sac, those behind it 
cold abscesses or serous or hydatid cysts. Exploratory puncture, 
though not free from danger, may be necessary for diagnosis, but when 
that is established it is better to operate as soon as possible. The 
method of operation depends on the situation of the dermoid; peri- 
neotomy is indicated if the tumour extends downward, the juxtasacral 
incision if it is high up, and either of these methods may, if necessary, 
be combined with the extraperitoneal abdominal. If discovered during 
labour, the tumour may be incised and drained, but should be extirpated 
as soon as possible after delivery. 

Solid tumours of the round ligament are occasionally encountered. 
They are rarely very large, and may develop either from the outer 
extremity of the ligament, when the neoplasm becomes extraperi- 
toneal, or, more properly, properitoneal; or they may develop within 
the peritoneal cavity, when they may be properly designated intra- 
pelvic. 

Weber (Societe d'Obstetrique et de gynecologie de St. Petersbourg) has 
reported 3 interesting cases of tumours of the round ligament. In 
one, the tumour extended from the inguinal canal into the labium 
majus. The growth was solid in character, containing a few small 
cavities filled with fluid; and was pronounced to be a lymphangeiectoid 
fibroma. In another of his cases, a myoma originating in the round 
ligament had developed within the abdominal wall. In his third case, 
a fibromyoma was discovered inside the peritoneal cavity, in the course 
of an operation for hernia. 

The treatment of these cases is necessarily by operation. In the 
properitoneal variety, the tumour is exposed by a long vertical inci- 



682 A TEXT-BOOK OF GYNECOLOGY 

sion, crossing obliquely the crural arch. Care is then taken to search 
for the portion of the tumour which lies in contact with, and occupies, 
the inguinal canal. If necessary, the inguinal canal itself should be 
opened by free incision, the dissection being carried far enough upward 
to enable the operator to enucleate the tumour, precisely as if it were a 
growth of the abdominal wall. When the tumour is intrapelvic, it is 
liable to be mistaken for one of ovarian origin. The operation, under 
such circumstances, is precisely like an ovariotomy, with the exception 
that the pedicle should be differently treated. It is to be remembered 
that, in cutting away the tumour, a segment of the round ligament is 
likewise being removed. This deprives the uterus of one of its anterior 
guy ropes, a defect which, if possible, should be remedied at the time. 
This may be accomplished by transfixing the two cut ends of the round 
ligament by means of a ligature and bringing them together, the ap- 
proximation being strengthened by a fold of the peritoneum, held in 
position by another transfixing but continuous suture. When these 
tumours are large, they sometimes cause backward displacement of 
the uterus, which should be remedied at the time of operation. 

Fibromyomatous tumours of the round ligament are very rare. They 
generally develop in the extraperitoneal segment. Delbet and Heresco 
(Revue de cliirurgie), in 16 cases of these tumours, found but 4 devel- 
oping from the intra-abdominal portion of the ligament. Claisse ac- 
counts for their relatively greater extraperitoneal development on the 
theory that that segment of the cord is more liable than the intra- 
abdominal portion to repeated, although probably slight, traumatisms. 
They grow to various sizes. Kleinwachter had a case in which the 
tumour developed 2.5 centimetres from the uterus and weighed 1,750 
grammes. Matthews Duncan reported one the size of a hen's egg; 
Winckel, one the size of a bean. In Delbet's case, the tumour weighed 
5 kilogrammes. In Segond's case, the growth in the ligament was 
associated with numerous similar growths in the uterus itself. Like 
the latter, they occur for the most part in women of middle or ad- 
vanced life, and are as liable to develop upon one side as upon the 
other. In their structural origin and evolution, they are analogous 
to fibromyomata of the uterus, although their manner of growth 
seems to be by perivascular inflammatory proliferation. 

Pelvic varicocele, aneurismal varix, and phleboliths, may be con- 
sidered under one head. Varicocele of the broad ligament is probably 
not as uncommon as is supposed. There are but few operators of long 
and extensive experience who do not come, accidentally, across cases 
of this kind in their abdominal and gynecological work; yet we find 
the literature upon this subject exceedingly meagre. The first case 
reported in this country was that of Dr. Dwight, of Boston, in 1877, 
quoted by A. P. Dudley, who, so far as Zinke is able to determine, 
wrote first in this country exhaustively on Varicocele in the Female 
and reported 4 cases (Neiv York Medical Journal, 1888, p. 147). 
Winckel found dilatation of the utero-ovarian veins not less than 10 



NEOPLASMS OF THE BROAD LIGAMENT 683 

times out of 300 autopsies. He also found thrombi. Both Klob and 
Bandl have found phleboliths (Pozzi). Dudley also quotes Brandt as 
having often seen stones, the size of peas, in the veins of the broad 
ligament. Eousan (These de Paris, 1892; Bagot, Denver Medical 
Times) states that pelvic varicocele is of frequent occurrence. Ed- 
ward Malins, of Birmingham (American Journal of the Medical Sci- 
ences, 1889, p. 340), writes interestingly upon Varicose Veins of the 
Broad Ligaments, and reports 2 cases. To this, Zinke adds 2 cases: 
one, an aneurismal varix of the right, and the other a phlebolith with- 
in the left, broad ligament. In the former case, an abdominal section 
was successfully performed for the relief of uterine hemorrhage in- 
duced by varicose conditions in the right broad ligament. This condi- 
tion was in turn brought on by previous labours and was aggravated by 
a laterally flexed uterus in the fourth month of gestation. 

In the second case a bilateral salpingo-oophorectomy and myomec- 
tomy resulted in the discovery of a phlebolith 4.5 centimetres long, 1 
centimetre thick in the centre, and tapering off toward each end, in 
the left broad ligament quite close to the uterus. 

The causes of varicocele and aneurismal varix of the broad liga- 
ment are, to say the least, quite obscure. Dudley in this country, 
Malins in England, and Winckel in Germany are about the only 
authors who have essayed to ascertain the etiological factors of this 
affection. Dudley divides the causes into, (a) constitutional, and (b) 
mechanical. Malins into general and local, which is practically the 
same. 

(a) Constitutional or general: Arrest of involution of the uter- 
ine and ovarian vessels, keeping up pelvic engorgement long after con- 
finement. A relaxed condition of the tissues from a low state of gen- 
eral health. x\n unhealthy condition of the vessel walls. An absence 
of valves in the veins. 

(b) Mechanical or local: The anatomical relations of the veins 
themselves; the spermatic and ovarian vessels being of such great 
length that the weight of such a column of blood has a tendency to 
weaken the vessels. Habitual constipation. Uterine displacement. 

As a reason why the left broad ligament is the more frequently af- 
fected, Dudley states: The emptying of the venous blood from the 
left broad ligament into the left renal vein is at right angles to the 
blood current from the kidney, and it obstructs the free flow of the 
blood from the ligament into the general circulation. 

Janni (Congress of Italian Surgeons, October, 1898) asserts that 
varicocele is not due to the retrogressive changes of the venous walls, 
conditional upon their expansion; but, frequently, to neoplasms of 
the elastic connective tissue of the intima, which assumes the form of 
an actual endophlebitis in knots or plaques, and is often accompanied 
by neoplasms of the connective tissue of the median vein. These neo- 
plasms have not the compensatory character ascribed to them by 
Eckstein (Cincinnati Lancet-Clinic, April 1, 1899). 



684 A TEXT-BOOK OF GYNECOLOGY 

Zinke believes the causes just cited to be without objection; but 
thinks that intra-abdominal pressure from any cause should be added 
to the list, and that for the formation of an aneurismal varix in 
this region, direct or indirect traumatism is necessary, as, for in- 
stance, external violence, frequent application of the forceps during 
labour, repeated abortion, operations upon the cervix, and diseases 
of pelvic organs. Phleboliths result from calcareous degeneration of 
thrombi. 

The history and symptoms of these cases, as Dudley correctly re- 
marks, are those of varicocele in the male. The pain is of a heavy, 
dull, aching character, most marked and much increased when the 
subject remains long in the erect posture; and correspondingly less- 
ened, and even followed by almost complete relief, when she is in 
the recumbent position for a long time. There may be a history of 
traumatism, malaise, nervousness, general indisposition, and even of 
melancholia. Frequent and profuse menstruation, or even metror- 
rhagia, in women past the menopause may be observed (Zinke). 

The diagnosis of varicocele must of necessity be very difficult and 
uncertain, if at all possible, even in well-marked cases. Varicosities 
and vein stones are, as a rule, recognised only when the abdomen is 
opened on account of other pathologic processes. The same may be 
said of aneurismal varix when not very large; otherwise it may give 
rise, as in Zinke's case, not only to a palpable, pulsating tumour, but 
to serious hemorrhages from the uterus, especially when complicated 
with pregnancy. Under certain favourable conditions, however, a 
diagnosis does not seem impossible in connection with the symptoms 
given. When limited to the broad ligament and free from thrombi, 
the knotted swelling felt with the patient in the upright posture, will 
be absent when the patient lies down, and only a doughy, thickened 
condition, will present itself to the finger in the vagina or rectum. 
If thrombi are present, the knotted condition will continue to exist, 
more or less. At all events, we must never be too sure of our diag- 
nosis. 

But little can be said as to the course and treatment of these cases. 
One or all of the three conditions may exist to some extent for a 
considerable period, and, perhaps, for a lifetime, and not give rise to 
any symptom whatever; or complications may be present obscuring 
the varix entirely. If discovered during an operation, the operator 
must determine as to what should be done for the relief or cure of 
the patient. Up to the present time, the experience of all writers 
and operators is very limited. Zinke has occasionally removed vari- 
cosities together with diseased ovaries and tubes ; and when, as hap- 
pened in one of his cases, the varix existed in the broad ligament 
alone and uncomplicated, he did not interfere, which he now believes 
was a mistake. Nor did it appear wise to him to attempt the removal 
of the aneurismal varix mentioned above, because of the existing preg- 
nancy and the injury done to the uterus by the sac forceps. It is, 



NEOPLASMS OF THE BROAD LIGAMENT 



685 



however, more than likely that, should another or similar ease present 
itself to him in the future, he would dispose of the evil in the man- 
ner pursued by Dudley, of New York, who operated upon 4 cases. In 
case No. 1, he was able to remove the varix with the ovary and tube, 
just as Zinke did in his three instances. In cases No. 2 and 3, Dud- 
ley quilted both broad ligaments close to the pelvic floor. All his 
cases recovered promptly, perfectly, and permanently, and he advo- 
cates radical treatment as the only means to do good. Bleeding by 
leeching or puncturing the cervix ; the daily use of irrigation with hot 
water; the tampon, a well-adjusted Hodge's pessary, and other local 
applications as recommended by Malins before removal of the vari- 
cocele is resorted to, will always remain palliative, not curative treat- 
ment. It is also doubtful whether the mere removal of the ovaries 
and tubes will invariably produce good results. 

Eeed operates upon varicocele of the pampiniform plexus by inter- 
rupted ligatures inserted at short intervals by means of a long-han- 
dled, curved needle (Fig. 295), and incision of the veins between 




Fig. 295. — " Interrupted ligatures inserted at short intervals by means of a long-handled 

curved needle. 1 ' 



the ligatures. This operation is applicable only when there exists 
no indication for the extirpation of the uterine appendages. Under 
the latter circumstances, the hemostatic ligatures should be made 
carefully to embrace the veins as well as the arteries, the veins being 
divided between the ligatures. Division of the veins is essential to 
the permanent success of the operation, as shown in Fig. 296, in which 
one section of the ligated veins has not yet been incised. 

The influence of the varix in the broad ligament upon the ovary 
manifests itself, according to the histological researches of Paul 
Petit, in two distinct phases ; one of engorgement, which renders the 
ovary cedematous and, later, hypertrophied ; and one of sclerosis, ter- 
minating in atrophy. 



686 



A TEXT-BOOK OF GYNECOLOGY 



Malignant Neoplasms: Carcinoma and Sarcoma of the Broad Liga- 
men t. — When the broad ligament becomes the site of malignant dis- 
ease it is, so far as we now know, of secondary origin ; in other words, 
it is the result of a primary affection of the uterus, vagina, ovary, or 
peritoneum. According to Pozzi, " Bandl has seen some cases where 
they came from the pelvic ganglia." To what extent the broad liga- 
ment may become involved, is best illustrated in a case related by 




Fig. 296. — ''Division of the veins is essential to the permanent success of the operation" 

(page 685). 

Howard A. Kelly in his work on Operative Gynecology, vol. ii, p. 331, 
wherein he says he found it " impossible to extirpate the disease in 
the broad ligaments and to check the free oozing from the diseased 
tissue which was cut; in order, therefore, to control the entire blood 
supply going to the part, I ligated both internal iliac arteries at a 
point 1 centimetre below the bifurcation of the common iliacs." 
Winckel refers to Chenieux, Duplay, Gortier and Hages, who have 
reported operations upon sarcomata of the broad ligament. 

An involvement of the broad ligament in cancerous diseases of the 
uterus and ovary is not rare; it is not so frequent when the bladder 
or vagina is the site of the primary growth. Zinke is of opinion that 
when the disease springs from the uterus and involves the vagina and 
broad ligament to but a limited extent, the total ablation of the dis- 
eased organs, glands, and tissues, through the abdomen will, in some 
cases, insure permanent relief. Zinke has 2 cases on record in both 
of which he performed total hysterectomy per vaginam eight years ago. 
Both patients are still living and in excellent health. One was fifty 
years old, and the victim of an epithelioma starting in the cervix and 
implicating by extension the corpus uteri, vaginal roof, and both broad 
ligaments. The operation was performed at the German Hospital, 
March 28, 1892. The other patient, aged forty-six years, had a sar- 
coma of the body of the uterus extending into both ligaments to a 
marked degree, but not sufficiently to cause uterine fixation. The 



NEOPLASMS OP THE BROAD LIGAMENT 687 

operation was performed on February 22, 1892, at the patient's home. 
Zinke now prefers the abdominal route in all cases showing involve- 
ment of the uterine ligaments. Though both the foregoing cases were 
attended by excellent results, he feels that the operation can be done 
with much more ease and thoroughness by going in from above. 



CHAPTEE XLIV 

INFECTIONS OF THE BROAD LIGAMENT AND OF THE 
PELVIC PERITONEUM 

Infections of the broad ligament — Pyogenic — Pelvic abscess ; treatment — Syphi- 
litic — Parasitic — Tuberculous — Tuberculous peritonitis, etiology, morbid anat- 
omy, miliary, caseous, fibroid, symptoms, diagnosis, prognosis, and treatment. 

Infections of the broad ligament may result from invasion by 
various micro-organisms, which may migrate thither from various 
points of entrance into the system, and through different highways of 
communication. Thus, the streptococci finding their original point of 
entrance in an infection atrium of the parturient uterus, reach the broad 
ligaments and the structures contained therein through the avenue of 
the lymphatics. The same may be said of the Bacillus aerogenes cap- 
sulatus, the staphylococci, and the toxine of syphilis, when the uterus 
is the site of the primary sore. On the other hand, it is exceedingly 
probable that the gonococcus, so fruitful of mischief upon the mucous 
surfaces, rarely if ever extends its ravages to the subperitoneal struc- 
tures, although it is a frequent cause of inflammation originating in 
the peritoneal side of the broad ligament. Echinococcous infection 
probably travels through the circulation, or else by direct invasion of 
cellular areas. It is probable that the colon bacillus reaches this locus 
by direct invasion of intervening structures. 

The pathology of infections of the broad ligament depends somewhat 
upon the micro-organism or other causative infectious element, and 
upon its avenue of ingress. When the lymphatic system is the high- 
way of invasion, the resultant phenomena may be, in the case of less 
virulent bacteria or toxines, nothing more than an acute nonsuppura- 
tive lymphangeitis (pelvic lymphangeitis) ; or, in the presence of more 
virulent elements, suppuration may ensue; while, as the result of 
chronic infection of syphilitic origin, there may result that form of 
hyperplasia of the lymphatics, known as gummata. 

Pyogenic infections depend chiefly upon (a) the streptococcus, 
(b) Bacillus coli communis, (c) the staphylococcus, and (d) the Bacillus 
aerogenes capsulatus. As elsewhere intimated, gonococci seldom play a 
part in the production of suppuration in this locality. It is unnecessary 
in this connection to attempt to distinguish clinically between these 
various forms of infection. A conclusion on this point may be reached 



INFECTIONS OP THE BROAD LIGAMENT 089 

by studying the general features of a given case, as, for instance, in 
puerperal fever; for, as a rule, infection within the broad ligament is 
only a part of the clinical and pathologic picture. 

Pelvic Abscess. — Suppuration in this locality may begin at multiple 
foci, or it may radiate from a common centre. It may be so circum- 
scribed as to defy detection by bimanual examination, or it may be so 
extensive as to lift up and separate the folds of the broad ligament and 
of the parietal peritoneum; such an accumulation of pus constitutes a 
tumour, upon the surface of which may be seen the tensely stretched 
Fallopian tube and the ovary, both uninfected. These are cases of true 
pelvic abscess. 

The treatment of pelvic abscess is by evacuation and drainage. This 
may be accomplished in various ways, the method to be selected de- 
pending somewhat upon the location of the pus sac. If careful bi- 
manual examination indicates that the accumulation of pus has ex- 
tended forward and lifted up the anterior fold of the broad ligament, 
and has thus resolved itself into an essentially preperitoneal abscess, an 
inguinal incision may be made. This should be done by making a 
careful dissection down to the upper margin of Poupart's ligament, 
after which the peritoneum can be lifted up and the abscess cavity be 
thus readied without opening the peritoneum. If desired, through-and- 
through drainage may be practised by making a counter opening in the 
fornix of the vagina and passing a tube through the external opening 
into and through the vagina. (See Fig. 231.) If the accumulation has 
burrowed far down along the vagina, vaginal puncture may be prac- 
tised, as elsewhere described (see Fig. 225), and permanent drainage 
may be established, either by the introduction of a self -retaining tube, 
or by the use of gauze. (See Infections of the Fallopian Tubes.) The 
operation formerly adopted by Tait, of making a median abdominal 
incision and stitching the wall of the abscess to the margins of the 
abdominal wound and draining in that way, may still be an operation 
of choice in exceptional cases. It, however, uniformly results in the 
formation of peritoneal adhesions, which must necessarily be the source 
of subsequent pain, and is, therefore, not to be employed under ordi- 
nary circumstances. Zuckerkandl operated upon these cases by placing 
the patient upon the side and making an incision obliquely on the 
affected side in the sacrococcygeal region. This becomes an available 
expedient in those cases in which the suppuration has extended behind 
the rectum and presents a fluctuating point in the postrenal region. It 
happens occasionally that pus burrows almost or quite to the vulva, 
under which circumstances an incision may be made vertically, a little 
to one side of the vulvoperineal region and about 4 centimetres long. 
The dissection should be carried up until the levator muscle is ex- 
posed, which should be pushed to one side, when the abscess cavity 
can be easily reached. This is the procedure adopted by Sanger, 
which has been modified by Zuckerkandl, who makes a transverse 
perineal incision in cases in which the purulent accumulation occu- 
45 



690 A TEXT-BOOK OF GYNECOLOGY 

pies both sides of the vagina. Eectal puncture has been practised by 
different operators, but while it is a convenient method of reaching 
the pus cavity in certain of these cases, it is always liable to leave 
a sinus which is difficult to control. 

Syphilitic infection, manifesting itself in the structures beneath the 
broad ligaments, is necessarily secondary to a primary sore of the 
uterus, or the upper portion of the vagina. If the primary chancre 
is located in the lower portion of the vagina, or upon the vulvar struc- 
tures, the superficial lymphatics are the first to be involved, the second- 
ary disturbance manifesting itself in the inguinal glands. Lymphangei- 
itis of syphilitic origin may be manifested, although rarely, in the lymph 
channels themselves, or, as is most generally the case, in the lymphatic 
glands (lymphadenitis). The lymphatic vessels may become acutely in- 
flamed and subsequently indurated, exhibiting the characteristics of 
tense, sensitive cords, within the more or less diffusely infiltrated con- 
nective tissue. Inflammation of the intrapelvic lymphatics occurs after 
the first or second week of an initial infection. Invasion of these glands 
is associated with fever, and with tenderness and enlargement of the 
glands themselves. They may reach the size of a hazelnut or a walnut, 
and they may or may not become the seat of suppuration. As a rule, 
however, the tenderness subsides after a few days, leaving the glands 
enlarged and but slightly sensitive to the touch. This enlargement, asso- 
ciated with but slight sensitiveness on touch, may persist from a few 
weeks to several years. In the irritative stage, there are marked hyper- 
emia, increased flow of serum, and enlargement of cells. The enlarged 
follicles of the gland present the appearance of grayish-white dots; 
with the recession of the circulatory engorgement, there occurs con- 
nective-tissue proliferation, and newly proliferated tissue elements 
show a marked tendency to become definitely organized, a fact which 
accounts for the persistence of glandular enlargement in these locali- 
ties. In some instances, however, cell proliferation progresses to such 
a degree that the newly formed elements can not be sustained by the 
blood supply, and then retrogressive changes are inaugurated. This 
may take the form of either a cell necrosis eventuating in what Virchow 
designated caseous metamorphosis, or of suppuration. In still other 
cases enormous gummata the size of a man's fist, may develop. These 
may be mistaken for fibroids of the uterus, or other fibromyomatous 
growths of intrapelvic origin. Eeed has seen two cases of this kind, in 
which the exact character of the enlargement was demonstrated. The 
diagnosis of syphilitic infections of the broad ligament is based chiefly 
upon an antecedent syphilitic history. The treatment is by that course 
of medication which is conveniently designated under the title anti- 
syphilitic. In cases of large gummata, the latter may be removed, ac- 
cording to their exact location, by either abdominal or vaginal section. 

Parasitic infection of the broad ligaments is chiefly restricted to 
invasion by the echinococcus. It is well known that the echinococcous 
disease may attack any organ in the body, and it seems, according to 



INFECTIONS OF THE BROAD LIGAMENT 691 

W. A. Freund, Wiener, and others, that the broad ligament constitutes 
no exception. It is asserted (Pozzi) that the echinococci " travel about 
in all the cellular interstices communicating with the superior pelvi- 
rectal space, which seems to be their point of entrance, and may thus 
reach the broad ligament, pass into the iliac fossa, and out of the 
pelvis either below or above the crural arch." Freund reported 18 
cases of echinococcus within the pelvis to the gynecological section 
of the Fifty-first Meeting of German Naturalists and Physicians at 
Baden, 1880. In 10 of the cases the diagnosis was proved by section, 
and in the rest, by puncture and operation respectively. It was Freund, 
too, who determined the site of the echinococcus in the pelvis, the road 
it travels, how it grows, its relations to the intestines, its spontaneous 
existence if left to itself, how to make the diagnosis, and the treatment 
to be pursued (Archiv fur Gynakologie, Bd. xv, 1880). 

In addition to the symptoms of the presence of a pelvic tumour or 
tumours, we shall have the symptoms characteristic of echinococcus; if 
the patient's health is good, as it often is, vocation, association with 
dogs (especially shepherd dogs), and country, will aid us in our diag- 
nosis. The hydatids often cause inflammation of the pelvic organs and 
adhesions between them. The cysts which form vary considerably in 
size; some may grow so large as to demand removal through the abdom- 
inal wall. When the inflammation is extensive, the disease may be 
mistaken for cancer. The cysts are filled, as a rule, with a clear fluid, 
nonalbuminous in character, and containing chlorides and sometimes 
traces of sugar (Osier). Suppuration may occur, especially when hook- 
lets are found; when they are absent, it is believed that the fluid is 
sterile and the cyst becomes harmless. 

Medical treatment of these cases is not very satisfactory. The 
cysts, if they become troublesome, may be attacked through the vagina, 
perineum, juxtasacral region or the abdominal wall. All will depend 
upon the location and size of the cyst. The sac may be completely 
enucleated or stitched to the wound and then drained. Freund (Pozzi) 
says: " If we have to cut through the peritoneum we must, so soon as 
we reach the sac and before opening it, use a tamponade of iodoform 
gauze for twenty-four or forty-eight hours, in order to assure hema- 
temesis, and the formation of protective adhesions; at a second seance 
we can open the sac under antiseptic precautions." 

Tuberculous infection of the broad ligament may be manifested in 
either the peritoneum (tuberculous peritonitis) or, in the underlying 
lymphatics. Tuberculous infection of the pelvic lymphatics rarely 
exists as an independent manifestation of the disease, but, on the con- 
trary, is but a local manifestation of a general involvement of the 
lymphatic system. Lymphadenomata of tuberculous origin rarely 
attain the size of those due to syphilitic infection. They are equally 
chronic in their manifestations. 

Tuberculous infection of the peritoneal folds of the broad liga- 
ment probably never exists, except as a part of the general tuberculous 



692 A TEXT-BOOK OF GYNECOLOGY 

infection of the peritoneum. In view of the fact, however, that the 
reverse proposition is equally true, there may be no impropriety in 
considering tuberculous peritonitis in this connection. 

Tuberculous Peritonitis. — Tuberculosis of the peritoneal cavity is 
one of the most important conditions that the gynecologist is called 
upon to treat. The disease is characterized by the development of 
minute miliary tubercles over limited or extensive areas of the peri- 
toneum, by ascites, by tumour formation, and by the development of 
caseous abscesses. 

Etiology. — The cause in all cases is the invasion of the peritoneal 
cavity by the tubercle bacillus. The method of this invasion is at 
times difficult to determine, and certainly varies in different cases. 
The infection may take place from the blood in a very few cases. An 
infection through the female genital tract has been found by Williams to 
occur in from 40 to 50 per cent of the cases, a fact which likewise has 
support in the greater frequency of tuberculous peritonitis in women 
than in men (Sippel). The female genital organs seem to afford 
an easy portal of entrance. Abbe has demonstrated that 66 per cent 
of the cases are infected from tuberculous thoracic lymph nodes, and 
16 per cent through the mesenteric lymph nodes. The alimentary 
canal, certainly, may be the source of infection, since it has been 
well demonstrated that the tuberculous sputum or fragments of tuber- 
culous lung (as used in animal experimentation) may cause an intes- 
tinal or a peritoneal tuberculosis (Klebs, Mosler, Jans). 

A previously depressed state of health does not seem to be a 
predisposing factor, since the majority of these cases look well nour- 
ished in the early stages of the disease, and have previously been in 
good health. Pregnancy shows a definite causal relationship which 
has not been adequately noted (Kelly). 

The age of the patient likewise seems to be a predisposing factor, 
since the collected cases of Osier show that the greater number occur 
between the ages of twenty and thirty, and that the two extremes of 
age are relatively immune. In regard to race, it has been shown that 
the negro is more frequently affected than the white. Hereditary 
transmission of the disease has been observed to be an important 
etiological factor. Brunn has observed such transmission in 55 per 
cent of his cases, Brehmer in 40 per cent, Desplans in 71 per cent, 
and Fuller in 60 per cent. A peculiar feature of the disease is the 
uncommon occurrence of grave tuberculous lesions in other parts of 
the body. Schroder states that it is a local phenomenon in 70.8 per 
cent of cases. The presence of a tuberculous peritonitis would seem 
to afford an immunity to tuberculosis elsewhere (Kelly). 

Morbid Anatomy. — The lesions of tuberculous peritonitis show de- 
cided variation in their manifestation, and permit of an indistinct 
division into a miliary, a caseous, and a fibroid variety. The mil- 
iary form may appear and exist for a long time without giving the 
slightest symptoms. On opening the abdomen for other reasons, the 



INFECTIONS OP THE PELVIC PERITONEUM 



693 



peritoneum of the pelvis or the entire peritoneal cavity is found to be 
peppered with minute miliary tubercles. The other appearances will 
vary greatly with the acuteness of the attack, the formation of adhe- 
sions, etc. In an acute miliary tuberculosis, the peritoneum is notice- 
ably congested and thickened, has lost its normal lustre, and shows 
fresh lymph on the inflamed surfaces. The fluid in the peritoneal 
cavity is yellow or bloody, and may be encysted by adhesions or free 
in the general cavity. The adhesions of the intestines to each other, 
or of the omentum, are not usually extensive because of the tendency 
to effusion, and they are usually frail and bleed easily. 

The caseous variety is characterized by a much more profound 
anatomical disturbance, by tumour formation, caseous abscesses, and 
severe interference with the functions of the intestine. In the most 
severe cases, the peritoneum throughout is the seat of a caseous tuber- 
culosis, all structures are agglutinated by the tuberculous pseudo- 
membrane, and the entire mass of intestine may form a firm tumour 
which is retracted against the spinal column. A variable number of 
encysted accumulations of yellowish caseous or purulent fluid may be 
included in the tumour mass. 

It is the rule, however, to find the disease more localized in the 
region of the pelvis, the caecum, the omentum or the liver. Under 
these conditions, the intestines adhere lightly or firmly together and 
may wall off the exudates in a more or less distinct sac which repre- 
sents the entire lesion, or 
a general ascites may co- 
exist. Such a sac may be 
mistaken for a cyst. This 
error may be avoided by 
observing (1) the fine 
white lines which mark 
the point of agglutination 
of the intestine by lymph 
and run parallel to it, and 
(2) a faint vermicular mo- 
tion after a sharp blow 
with the finger. If such 
collections become puru- 
lent, they may lead to ul- 
ceration and intervisceral 
or external fistulse or they 
may burrow extensively. 

When the disease is lo- 
calized in the omentum 
(Fig. 297), this organ be- 
comes greatly thickened, but at the same time puckered and rolled 
up to form a firm, elongated tumour lying transversely across the upper 
part of the abdomen. This tumour may subsequently caseate and 




<£ ~- 



Fig. 297. — " When the disease is localized in the omen- 
tum, this organ becomes greatly thickened.'" a, Typ- 
ical round-celled miliary tubercles. — Whitacre. 



694 A TEXT-BOOK OF GYNECOLOGY 

ulcerate either externally or into the intestine, but such a termination 
is extremely rare. 

Pelvic tuberculous peritonitis is generally associated with tubal 
tuberculosis and in this type of the disease is generally represented 
by cystic formation and extensive binding down of all pelvic struc- 
tures into one hard mass. The cyst may extend well above the pubes, 
and the entire pelvis is covered in by a thick, friable, grayish, tuber- 
culous membrane, which is likewise adherent to the intestine above. 
The pelvic peritoneum is certainly the most frequent seat of tubercu- 
lous peritonitis, and this fact has been explained by Weigert, who has 
demonstrated that the tubercle bacilli always fall to the bottom of the 
peritoneal cavity. 

The fibroid type of tuberculous peritonitis is in reality a terminal 
stage of the preceding varieties, more especially the first. The miliary 
tubercles are found in a quiescent stage with few cellular elements 
and very few bacilli, while old adhesions and tuberculous masses have 
almost entirely lost their tuberculous nature, and have been converted 
into firm fibrous tissue. 

Symptoms. — It will be seen from a study of the lesions of tuber- 
culous peritonitis that the symptoms may be entirely absent, or may 
possess all the severity of an extensive inflammation of the perito- 
neum, and be associated with those of intestinal obstruction. 

Certain indefinite prodromata, such as loss of appetite, loss of 
flesh, digestive disturbance, or an afternoon fever, may be present, but 
many cases begin as a sudden attack of acute peritonitis with a tem- 
perature as high as 103° F., acute abdominal pain, tenderness, and 
ascites. These symptoms subside after a few days and the patient 
continues with a persistent digestive disturbance, indefinite pains, an 
afternoon rise of temperature and some tenderness. The most con- 
stant symptom of the slower form of onset is pain referred to the 
lower abdomen and pelvic organs, and associated with menstrual dis- 
turbance. This pain varies all the way from a continuous ache to a 
most intense suffering that confines the patient to bed (Kelly). It is 
described as a bearing-down pain, as shooting pains, or by the negro 
as a " misery." The pain is usually associated with tenderness over 
the lower abdomen. 

Swelling of the abdomen and a sense of " bloating," are also fairly 
constant features, dependent at first almost entirely upon tympanites, 
but, later, ascites adds to the swelling. This is usually associated 
with loss of appetite, dyspeptic symptoms and constipation. . 

Fever is a marked symptom in the acute cases and fairly constant 
as an afternoon rise in the more chronic forms. In the latter it 
reaches 99° to 100° F. and the patient complains of having " malaria " 
or " chills and fever." 

Pain in urination is given by Kelly as the most characteristic of 
all the symptoms. 

Berggriin and Katz have found that an abundance of fat in the 



INFECTIONS OF THE PELVIC PERITONEUM 695 

stools of infants is a valuable diagnostic point. They state that, while 
the bile is fully secreted and acts normally to prevent putrefaction, 
the work of fat digestion is imperfectly done. 

A striking peculiarity of the condition is the frequent occurrence 
of an abdominal tumour. These tumours are omental, the result of 
sacculated collections of fluid, are made up of adherent masses of 
intestine that have become thickened and retracted, or they are formed 
by enlarged mesenteric glands, especially in children. They give the 
most confusing physical signs that are ever encountered in abdominal 
surgery, yet their very anomalous nature has come to be looked upon 
as one of the diagnostic features of peritoneal tuberculosis. An appar- 
ently solid tumour will give tympanitic resonance, the confines and 
the relations of the tumour will often change between two examina- 
tions, tympanitic resonance will persist in the flanks in the presence 
of a considerable effusion because of the encysted condition of the 
fluid, and, finally, such tumours of the uterine appendages or in the 
region of the caecum may simulate those of pyogenic origin. 

Diagnosis. — The diagnosis of this condition presents many difficul- 
ties, since the signs that are characteristic of tuberculosis in other 
parts of the body fail us here, and it is a well-established fact that 
many cases of tuberculous peritonitis are not diagnosticated before 
operation. Xevertheless, experience has taught us that a diagnosis 
may usually be made with certainty (a) when the abdominal condition 
is associated with extensive pulmonary disease; (b) when tubercle 
bacilli are found in the uterine secretions or curettings, and (c) when 
an anomalous mass of slow formation is found in the pelvis and is 
associated with an ill-defined fluctuating tumour of the lower abdo- 
men that changes its relations from time to time. 

Bulius has called attention to the diagnostic value of tuberculous 
nodules in the pelvic peritoneum. These vary in size from that of a mil- 
let seed to that of a bean, and may often be distinctly felt on the broad 
ligament, the Fallopian tube, the lateral wall of the pelvis or on the pos- 
terior surface of the uterus when this organ is pulled down by a vol- 
sella and examined per rectum. The sensation is that of a grater. 
The other conditions in which such nodules may be encountered are 
metastatic carcinoma, papillary cystoma of the ovary, and the small 
blisters of certain forms of peritonitis. Edebohls has placed positive 
diagnostic value on a plaquelike thickening of the peritoneum. The 
exclusion of abortion or gonorrhoea in the presence of a lateral mass 
will make a diagnosis of tuberculosis probable (Morris), but it must 
be remembered that abortion sometimes acts as a predisposing factor 
in tuberculous peritonitis. The simultaneous occurrence of pleurisy 
with effusion, especially when this fluid is bloody, is a very important 
diagnostic sign. A careful personal and family history of the case 
should never be omitted since heredity, the history of previous attacks 
of peritonitis, the history of " chills and fever," a gradual increase in 
the swelling, a more or less constant pain increased in walking, an 



696 A TEXT-BOOK OF GYNECOLOGY 

uncertain percussion note, and loss of flesh, are among the most im- 
portant clinical diagnostic points. 

Finally, the diagnosis has been made absolutely certain, according 
to some authorities, by the use of tuberculin. If no reaction takes 
place, the tuberculous character of the peritonitis is excluded. 

It must be remembered that the tubercle bacilli are rarely found 
in the ascitic fluid. But they may be found in the uterine or vaginal 
secretions, or the ascitic fluid may be injected into the peritoneal cav- 
ity of guinea pigs. 

The acute cases may be distinguished from typhoid fever by a 
previous history of abdominal pain, the absence of rose spots, the 
absence of diarrhoea and continuous fever, a distinct induration in 
the region of the cascum, and the absence of the Widal reaction. 

Osier states that of 96 cases, 30 were diagnosticated as ovarian dis- 
ease. In the diagnosis between tuberculous peritonitis and ovarian 
cyst, we are guided by the history of antecedent disease of the append- 
ages, the rapid development of an effusion, the ill-defined nature of 
the fluid tumour, a coincident pleurisy, the bacteriological examina- 
tion of the uterine secretions, and by a most accurate bimanual ex- 
amination made per rectum when the uterus is drawn down. 

Prognosis. — The age of the patient, the advanced state of the dis- 
ease, and the character of the operative treatment, will all determine 
the prognosis in tuberculous peritonitis. The cases that do well are 
those in patients of middle age who have a considerable effusion of 
fluid either free or sacculated; while the dry forms and those cases 
with extensive adhesions of the intestines are likely to do badly. 

Treatment. — Osier has justly stated that a great many cases of 
tuberculous peritonitis recover spontaneously, but it must be remem- 
bered that errors of diagnosis form a constant factor in such cases, 
and that a diagnosis often can not be made without an abdominal sec- 
tion. Furthermore, the nontuberculous type of peritonitis described 
by Ousserow, and also by Henoch, as " peritonitis nodosa," which is 
identical in appearance with miliary tuberculosis of the peritoneum, 
must form a constant source of error in medical cases. 

The treatment of tuberculous peritonitis is invariably by laparot- 
omy, and no case should be abandoned as hopeless unless actually 
dying or in such feeble condition that the operation itself would be 
fatal. Simple incision and immediate closure of the wound without 
touching a single viscus, or the evacuation of the fluid, has resulted 
in a cure of the condition, but the indications of the individual case 
must be met and certain principles adhered to in the performance of 
these operations. 

The operation should have for its object the removal, if possible, of 
the focus of the disease, the removal of serous or purulent exudate, and 
the release of dangerous or painful adhesions. 

The length of the incision will vary with the amount of manipula- 
tion that is necessary within the abdominal cavity. The uterine ap- 



INFECTIONS OF THE PELVIC PERITONEUM 697 

pendages should be removed whenever they are involved, and the 
difficulties of the operation in the advanced type of the disease are 
certainly very great. All structures below the brim of the pelvis are 
bound together in one rigid, friable mass; enucleation of the tumour 
without rupture of the intestine requires the most painstaking care; 
and nothing short of a raw, uncovered condition of the pelvis can be 
left behind. 

The fluid in the peritoneal cavity is either free and requiring no 
special effort for its removal, or it may be sacculated and require a 
careful tearing of adhesions for its relief. Single adhesions should 
be released, but when the intestines are bound together in one mass 
they should not be touched. Certain operators advise flushing the 
peritoneal cavity in every case and the thorough mopping out of every 
part of the fluid, while others would irrigate only the pus cavities. 
The question of drainage in these cases has been rather definitely set- 
tled in favour of the immediate closure of the abdomen, unless there 
are distinct pus sacs which demand drainage. 

Many theories have been advanced with considerable sagacity to 
explain the manner of the healing after abdominal section, but we 
are still without a positive explanation. It was first thought that the 
cures were accounted for by the presence of a " nodular peritonitis " 
instead of the true tuberculous peritonitis, but a great number of 
cases are on record in which the diagnosis has been made from the 
tissues or fluid removed at operation, and a disappearance of the tuber- 
culous process has been demonstrated at a later date by autopsy or by 
subsequent operation. The removal of the exudate was supposed to im- 
prove the peritoneal vitality and resorptive power by relieving the em- 
barrassment to the blood and lymphatic circulation (Bumm); but this 
is inadequate, since the dry forms are also healed by operation and 
mere tapping does not often result in healing. The use of antisep- 
tics (iodoform, mercuric bichloride, etc.), can not explain the good 
results, because the improvement is much more satisfactory when none 
are used. The modern surgeon has suggested that certain bacteria 
which develop a toxine that is antagonistic to the tubercle bacillus must 
gain entrance at the time of operation. The germicidal action of air 
and sunlight on the tubercle bacillus was suggested by Koch as an ex- 
planation, but it is apparent that such action is only momentary, that 
it can not possibly reach the deeper pouches of the peritoneum, and 
that lupus of the face would not exist in the presence of such an 
action. Warnecke first suggested hyperemia of the peritoneum fol- 
lowing handling, sponging, flushing, or the contact of air, as the heal- 
ing factor, and others insist upon the antibacterial action of the exudate 
that is immediately poured out (Sippel, Satti). Hildebrandt has dem- 
onstrated on animals that a laparotomy can only have its full effect 
when, in the natural life history of the tuberculosis, the retrograde 
process has already set in; and he believes that the assistance to healing 
given by laparotomy is the result of a persistent venous hyperemia. 



698 A TEXT-BOOK OF GYNECOLOGY 

The injection of sterile air by Nolen can have no value, while the 
explanation of Bumm and Buchner, of a healing by phagocytosis and 
alexine formation, may have some importance. It is probable that the 
combined action of a number of these agencies will explain the healing 
that takes place. 

The percentage of cures following operation is placed by Parker 
Syms at about 30 per cent as a result of a comparison of statistics 
varying from 24 to 80 per cent. Konig reports 131 cases in which 
24 per cent were healed for over two years, 65 per cent under two 
years, and 3 per cent died after operation. At any rate, laparotomy 
must be looked upon as a life-saving measure that will be necessary in 
a majority of cases and having only the very low mortality of 3 per 
cent. The operation is not contraindicated in slight involvement 
of the lung, but should not be done when an acute miliary tuberculosis 
is present. 



CHAPTER XLV 

MENSTRUATION 

Normal menstruation — Time of appearance — Menstrual cycle — Quantity of dis- 
charge — Character of the discharge — The inducing cause of menstruation — 
The role of the uterus — The role of the Fallopian tubes — The role of the 
ovaries — The hygiene of menstruation. 

Normal Menstruation. — If we say that menstruation is a sanguineous 
flow from the genitals of ivoman, lasting four days at each recurrence, 
and appearing at regular intervals of twenty-eight days from the dawn 
of puberty until the child-bearing period has passed, we have made a very 
fair definition; but every separate statement contained in it is sub- 
ject to many exceptions. 

For, in the first place, menstruation is not peculiar to woman. In 
her, to be sure, the function has risen to its highest; but, none the less, 
it is an inheritance, and she, in menstruating, is not unique. In a 
number of our domestic animals at the time of maximum sexual ex- 
citement, there is a very notable flow of mucus from the vulva, and this 
mucus is oftentimes loaded with anatomical elements, young cells, and 
a small amount of blood. Millikin has observed this tinge in the case 
of the cow and the mare, and it has been reported as present in the 
female dog and in a number of apes and monkeys. 

Walter Heape {Proceedings of the Royal Society, No. 361) has given 
an excellent account of Macacus rhesus, an Indian monkey, which has 
a definite breeding season but menstruates with regularity through 
the whole year. At the menstrual period, macacus displays a certain 
congestion of the skin upon the abdomen, legs, and tail, and to these 
simian symptoms adds the strictly ladylike features of swelling and 
congestion of the nipples and vulva, and flushing of the face. At the 
same time, there is a discharge of viscid menstrual fluid, mostly white, 
but containing red corpuscles, uterine debris, stroma and epithelium. 
Menstruation in S em no pith ecus, as observed by Mr. Heape, corre- 
sponds very closely to that in macacus. 

Curiously comparable to this is menstruation among the lowest 
savages of southern Africa. James Stirton, in the Glasgow Medical 
Journal, supporting a contention that menstruation is a product of 
civilization, says that in the lowest tribes accessible to him he found 
menstruation to be very scanty and irregular, and always inaugurated 
by a prolonged mucous flow which never became highly sanguineous. 

699 



700 A TEXT-BOOK OF GYNECOLOGY 

There appears to be a gradation leading us from dry mammalian 
rut to the rutting with discharge of the highly artificialized domestic 
animals, thence to the menstrual rut of the quadrumana, and thence 
to the highly sanguineous flux of the human female. It is a biologic 
fact that the higher mammals menstruate when in heat; it is no slan- 
der to say that woman is in heat when she menstruates. Confirmatory 
of this is the fact, often obscured by the self-control belonging to 
women of the highest and most refined type, that the beginning of 
a menstrual flow tallies with an acme of sexual desire, insomuch that 
considerations of modesty and convenience will not always deter them 
from absolute solicitation at the menstrual time. 

Against the identity of menstruation and rutting it has been urged 
that menstruation continues with regularity through the year, whereas 
rutting is a phenomenon of some particular time of the year; and the 
fittest answer is that the females of those animals which have been 
most artificialized by domestication, tend to come in heat at regular 
intervals through the whole year, after the manner of women. The 
mare, for example, tends to come in heat every three weeks, and the 
female dog who escapes pregnancy will also develop a regular period. 
That is to say that, when living under human conditions, they tend to 
human menstruation. 

It should be noted that the heat of wild animals is determined by 
two causes, the arrival of spring and the greater food supply which 
comes after a time of relative scarcity in most climates. Human fore- 
thought and ingenuity have practically annulled the influence of the 
seasons and have made the supply of food constant over the greater part 
of all the earth. But where degraded tribes exist in primitive con- 
ditions, virtually in a feral state, we find that women return to the 
animal type of menstruation. In the long, bright days of the Arctic 
summer, the Eskimo men and women pass into a state of ecstatic 
sexual excitement which is terminated only by satiety and exhaustion. 
It is at that season that the women become pregnant, for the most 
part. The comparatively refined women of Greenland often cease to 
menstruate during the long dark winters, and similar observations have 
been made in the high mountain regions of France and Switzerland. 
Barnes says flatly that some women menstruate only in warm weather. 
The immigrants who came to our shores forty years ago, after long 
voyages on short rations, came, as was often observed, in excellent 
health, but in a condition of amenorrhcea. In our north temperate 
zone, it can be shown that women of the robust type who nurse their 
children and do not limit their fecundity, have a tendency to bear 
children every second year in midwinter. So frequently does this 
occur that it leaves room to question whether there may not be still a 
breeding season for the human female, a faint fossil relic of primeval 
times. 

In a comparative study, it must ever be remembered that perturbing 
influences tend to induce a more prolonged and uniform sexuality in 



MENSTRUATION 701 

the human female. Her purely animal lust is complicated with spir- 
itual affection for her mate, and this is in conformity to high poetic 
ideals; it is fused with aesthetic ideals, also; it finds its ethical restraints; 
and all of these human complications are only faintly prefigured in 
the psychology of the lower animals at the breeding age and the breed- 
ing season. With woman, primeval sexual instincts are continually 
cooled by prudence, modesty, conventional prudishness, and high intel- 
lectuality; it is inevitable that advancing refinement, and even in- 
creased comfort in life, should cause the phenomena of rutting to 
take on a less furious character and, as a corollary, a more uniform 
character through the year. And so the cycle of human rutting be- 
comes much shortened. 

It may well be that the function of menstruation will disappear in 
the course of ages, but in its last waning recurrences it will still be 
cyclical in its manifestations. It is a law of life and of all activity. 
The respiratory movements are rhythmic, and by a deeper breath at 
every seventh or eighth respiration we graft rhythm upon rhythm. 
There is a recurrence of hunger and of the propensity to sleep which 
is not in exact correspondence with the needs of the organism. In 
healthy persons of both sexes there is a diurnal tide in the pulse rate, 
the respiration, the arterial tension and the temperature. More than one 
competent observer has come close to a demonstration of that which is 
inherently probable — a tidal movement in the adult male of the human 
species during which all vital processes and the sexual appetite reach a 
climax and then decline to a minimum, so that the question has been 
seriously raised whether it is not true that men menstruate as well as 
women. And if we make the easy step from the physiological to the 
pathological, we find the same inexorable law of rhythm in the periodi- 
cal recurrence of malarial paroxysms which the plasmodium has not 
fully explained, of epileptic seizures, of maniacal crises, and in the 
characteristic fever curve of the acute infectious diseases. Even in the 
highest intellectual activity we find the same law, for the creative power 
of genius has its ebb and flow. 

The Time of Appearance. — That menstruation usually comes with 
puberty is a matter of common knowledge. In the United States that 
age may be put at fourteen years and six months, with wide individual 
variance from this average. Very frequently the function announces 
itself and is heard of no more for months; irregularity for the first 
year is too common to excite the alarm of most mothers. 

Precocious menstruation may appear even in infancy. Hungry for 
marvels, women will often bring the baby's first diaper with a red 
stain upon it, and this is presented for blood in the case of a boy, and 
for menstrual fluid in the case of a girl. In almost every case the red 
patch will be found to be gritty under the finger, and its free solubility 
in warm water will confirm the diagnosis of red urates. Sometimes, 
however, in the case of girls, a small amount of blood will be found 
to come from a vulvo-vaginitis, with or without gonococci. Even 



702 A TEXT-BOOK OF GYNECOLOGY 

more rarely, granulations exist about the urethral opening sufficiently 
large and weak to produce a stain of blood. Millikin recalls a very 
puzzling case of a little girl who did not cease to " menstruate " until 
after a course of antisyphilitic medicine. The mother's many abor- 
tions furnished the clew to a diagnosis, confirmed after years by the 
child's dentition and the development of periosteal nodes. But a 
menstrual flow from the uterus of a healthy child is not to be denied. 
It may appear under the stimulus of disease, as in a case reported by 
Gemmell (British Medical Journal, vol. i, 1892), where a healthy girl of 
nine years, not hemophilic, had a flow of blood, squamous epithelium, 
and debris, which continued five days following the height of the erup- 
tion of measles. 

There are many cases reported showing the menstrual tendency so 
strong that no stimulus of acute disease is needed to bring on the flow 
precociously. Millikin knows a case of two girls in whom puberty 
came, by gradual and symmetrical development, at the ages of eight 
and eight and a half years, respectively. Here, menstruation was a 
mere incident to perfect womanhood, for, though these little women 
had not attained their full stature, they had acquired rich voices, they 
cared little for children of their own ages, one of them suddenly be- 
came very averse to school, and the other attended to household matters 
with womanly enthusiasm. 

More extreme cases may be cited, but here we trench upon the mon- 
strous or the pathologic. Plumb (New Yor~k Medical Journal, June 
5, 1897) reports the case of a child that weighed 9 pounds at birth, 
had genitalia similar to those of a girl of seven years, had pubic hair, 
but none in the axilla, and had a clitoris an inch and a quarter in 
length and of a diameter of half an inch. The mammae were an inch 
in thickness and an inch and a half in diameter. Bathing the breasts 
caused erection of the clitoris; contact of clothing with the clitoris 
caused a complete orgasm. Amputation of the clitoris relieved her 
of reflex nervous disturbance. At six weeks she began to menstru- 
ate, and so continued until the age of six months when the report was 
made. 

Irion (op. cit., August 15, 1896) gives account of a girl of 9 pounds' 
weight at birth, with breasts and mons veneris well developed. She 
menstruated at the age of seven days, the flow continuing four days. 
A month later there was no flow, but from that time until the child 
was ten months old she was reported " regular." 

Wladimiroff (Archiv fur KinderheiTkunde, 1897) reports the case 
of a rhachitic girl, six and a half years old, 4 feet high, weighing 
50 pounds. Her breasts, pubic hair, voice and modesty, all proclaimed 
her a little woman. She had menstruated once. 

Klein (Deutsche medicinische Wochenschrift, 1899, No. 3) gives an 
account of a girl of ten months who had been separated from her 
parents up to that age. She was then found to be menstruating. She 
menstruated regularly for nine months. Then she had amenorrhcea 



MENSTRUATION 703 

for four months, and then menstruated for seven months. At that time 
she had an attack of measles and ceased to menstruate for many 
months up to the time of the report. She was a delicate child of good 
mental development. Her breasts were of womanly shape and her 
genitals were large, with pubic hair. 

Howie (Year Book, Gould, 1898) reports the case of a girl who men- 
struated from the age of three years and fourteen days. At each period 
she was languid and suffered malaise. She had pubic hair and promi- 
nent breasts. 

Morse (op. cit.) reports the case of a girl who began to menstruate 
at the age of nine months. 

Price (op. cit.) gives a case in which the child menstruated from 
the age of four years. Pubic and axillary hair appeared at eighteen 
months. Her breasts and bodily contour were womanly. 

Lopez (Revista de la Sociedad Medica Argentina) reports the case 
of a child of five years which menstruated from the age of eighteen 
months. Each flux was of from three to five days' duration. The ex- 
ternal appearances were those of maturity. The little creature was 
cursed with ardent sexual passions. 

Rein exhibited before the Kieff Obstetrical Society a girl of six 
3^ears who had menstruated regularly for a year. The breasts and ex- 
ternal genitalia were appropriate to a girl of thirteen or fourteen years. 
The abdomen was enlarged, and a fluctuating, thick-walled cyst was 
diagnosticated. 

Sometimes the ripe femininity of these little creatures is attested by 
maternity. Thus, McLaury, of Xew York city (American Journal of 
Oostetrics, 1887), sent a girl of thirteen years to a lying-in hospital. 
From her earliest recollection she had cohabited with men and boys. 
It is an interesting fact that she was one of four children born to an 
unmarried woman. 

In 1858 there was a young mother, not quite eleven years old, living 
at the public charge at Taunton, Mass. 

Dr. Gleaves, of Virginia, has reported the case of a girl who at 
the age of ten years and two months was delivered of a child of five 
pounds. She had menstruated from the age of five years. She had no 
mammary development, and her baby, during its short life of one 
week, was suckled by its grandmother, who had a child of only a few 
months. 

These last cases might hardly be called exceptional in warm coun- 
tries where men and women are so soon ripe and so soon rotten. In 
Ceylon a youth attains his majority at sixteen years and one may find 
the girls mature at from eight to fourteen years. Even in Mexico it 
is not uncommon to meet with grandmothers who are but little be- 
yond the age of twenty years, and some cases fall much within this 
limit. One author, representing no extreme views, has stated that 
the average age of first menstruation is twelve years at the tropics, and 
sixteen years at the coldest civilized regions. 



704 A TEXT-BOOK OF GYNECOLOGY 

The Menstrual Cycle. — The menstrual month is a myth which has 
no other basis than the obscure moon-worship, latent in our race. For 
each woman, a definite and precise cycle is usually established, early in 
her menstrual life, but that cycle is seldom measured by precisely 
twenty-eight days. Vast numbers of women menstruate scantily every 
two weeks and enjoy perfect health. Upon inquiry, it will be found that 
many women menstruate every three weeks. A very large number of 
women are delighted to know that they conform to the classic period 
of twenty-eight days, but make their reckoning from the end of one 
period to the beginning of the next, so that they really have a cycle 
of about thirty-three days. In the same group are those who compla- 
cently declare that they are regular as the clock because they men- 
struate always on the same day of the calendar month. Millikin knows 
a case of two sisters who were in excellent health, but much dis- 
turbed because of menstrual irregularity, and it took much patient 
investigation to determine the fact that they had periods of thirty- 
seven and forty-nine days, respectively. 

There is, in truth, no normal period of menstruation except in the 
sense that there is an average period of about twenty-eight days, from 
which most women depart widely. Exact conformity to this period 
brings no added grace, health, or fecundity; and contrary to the com- 
mon belief among women, departure from it brings no peril. As a 
general rule, women highly refined and of delicate tissues will men- 
struate more frequently, while coarser, more robust women will men- 
struate less frequently. 

The Quantity of the Discharge. — At each menstrual period, the 
human female loses from 2 to 14 ounces of fluid. As the estimate must 
be made from the collection of a few hours, it is not surprising that 
the range of variation should be so great. Individual differences are 
known to be very great, for, while one healthy woman will have merely 
enough discharge to stain her clothing, another, equally healthy, with 
like fixity of habit, will soak her cloths for two or three days. 

No other mammalian female loses so much blood as woman. This 
we explain, first, by the fact that the reproductive apparatus of the 
lower animals has no other purpose than reproduction, whereas, in 
the highest of mammals it ministers to complex loves and likings and 
lusts which are only incidentally or accidentally reproductive. If the 
stimulus brought to bear upon the genitalia of the human female were 
ten thousand times less than it is, it would still suffice for the perpetua- 
tion of the species. There is therefore an abnormally high functional 
activity of the human uterus and all that pertains to it, if we allow 
the lower animals to fix the norm, and with this goes abnormal conges- 
tion and a tendency to increased leakage. 

In the second place, it may be observed that the erect posture of 
the human female distinctly invites a free supply of blood to the pelvic 
organs and hinders its return to the heart. Such indeed is the law of 
all parts of the body lower than the heart. Man, the monarch of all 



MENSTRUATION 705 

living things, erects himself in appropriate attitude and pays the pen- 
alty of his arrogance by suffering from varices, hemorrhoids and pre- 
carious nutrition of his hinder legs: his poor mate, to these lesser 
plagues, adds her characteristically profuse menstrual flow. We may 
add, as a third consideration, that the delicate tissues of the highly 
civilized woman are poorly able to resist the influences which tend to 
leakage of blood at the menstrual time. 

In temperate zones the average duration of menstruation is about 
four days and a half. In any locality may be found great numbers of 
women who habitually menstruate two days, and as many who men- 
struate seven days. 

Character of the Discharge. — There are occasional cases which fur- 
nish what has been well called white menstruation. The subjects usu- 
ally announce themselves as suffering from a leucorrhoea which is 
" very weakening.'' Investigation, after excluding gushes of fluid 
from diseased tubes, and after establishing the periodic character of 
the discharge, will properly refer it to an attempt at menstruation 
which goes no farther than engorgement and supersecretion of the 
uterine glands. White menstruation is not pathologic and certainly 
does not demand surgical treatment. 

The ordinary menstrual fluid is composed of mucus which comes at 
first from the uterus alone; at a later stage, the vaginal glands are 
also active and pour out their share of mucus. At an early stage, 
blood is mixed with this mucus, and the fluid takes on the tint of 
venous blood, or, by rapid decomposition of corpuscles, it becomes 
brown or black. Ciliated epithelium from the uterus is abundant, 
and a small quantity of epithelium from the vagina is also present. 
Remains of the endometrium are to be found abundantly. Fatty acids 
are present to give to the fluid its characteristic odour, and to prevent 
the coagulation of the menstrual blood. When the blood is present 
in high proportion, possibly because of a low amount of mucus and 
acids, clots form, to the dismay of the subject. Of all the compo- 
nents of the menstrual fluid, the blood is probably the least impor- 
tant. The hemorrhage is merely an untoward accident occurring in 
the course of important significant changes within the uterus. 

That menstruation is an excretory process during which " bad 
blood " and nameless poisons are excreted, is an error possessed of 
notable vitality, for it has lived long and it dies hard. No one has 
suggested a mode or an avenue of elimination for this poison in men, 
boys, old women, pregnant women, little girls or women in whom sur- 
gery has brought on an artificial menopause; no one has detected it 
in the discharges; no one has pointed out any essential difference 
between women who menstruate freely and those who menstruate 
scantily. Nevertheless the fancied peccant substances will remain 
in literature for another century. 

Millikin knows of courtesans enjoying excellent health who, with 
more knowledge of their trade than of transcendental pathology, have 
46 



706 A TEXT-BOOK OF GYNECOLOGY 

learned the trick of suppressing the menses at will by the use of tightly 
packed sponges. A. W. Parsons, of Northampton, Mass., has taught 
many patients to tampon the vagina, partly for the comfort and neat- 
ness secured, and partly to limit the amount of discharge as might be 
thought good. In 1888 Gehrung recommended (American Journal of 
Obstetrics) the use of an alum-soaked tampon to be retained for 
forty-eight hours unless there should be leaking through or around it. 
He uses this tampon boldly to abbreviate or lessen the flow at his 
pleasure or to hasten the menopause. It was his deliberate purpose 
to reduce the flow to a limit of from 2 to -i ounces, and this was ac- 
complished in his therapy without a hint of harm. Loewenthal, in 
June, 1888, advocated the restraint of menstruation by intrauterine 
injections of hot water, or, occasionally, of iced water. He had 
greatly benefited 18 cases of chlorosis by suppressing menstruation for 
from three to five months. 

The Inducing Cause of Menstruation. — Then, throwing aside the 
notion that the menstrual fluid is cast out by an active effort of the 
system to rid itself of a poison or a group of poisons, we inquire fur- 
ther into the inducing causes. From the very beginnings of medical 
literature, there is a hint that the blood of the human female was 
rich enough to force an overflow every four weeks, this capacity for 
plethora being born and bred in her for the benefit of her pos- 
sible offspring. Without a fact to support it, this teleologic theory 
was unchallenged until late in the present century. More recently 
a very popular theory was, that Nature prepared a decidua for the 
coming ovum and that, when impregnation failed, for any cause, 
she entered upon a house-cleaning process which involved the cast- 
ing off of the decidua, and, as Christopher Martin said, poured out 
a flood of blood from the turgid capillaries to wash away the use- 
less debris. 

Of late, some have been strangely impressed with the fact that 
the uterus has a rich nervous supply, its sympathetic fibres re-en- 
forced by spinal filaments given off from the abdominal splanchnics, 
which send filaments to the uterus by way of the hypogastric plexus, 
and re-enforced also by fibres from the pelvic splanchnics which also 
pass through the hypogastric plexus on their way to the generative 
organs, the bladder, and the rectum. It has caused admiration, also,, 
that the uterus has its own ganglia, giving it independent movement, 
even when dissevered from the body, and it has been announced that 
the uterus has anabolic nerves to retard, and katabolic nerves to accel- 
erate, its metabolism. 

But in all this, the uterus is not singular; its nervous organiza- 
tion is in every way comparable to that of other important viscera, 
for we believe that they all have motor, sensory, vasomotor, and 
trophic nerves. That the function of menstruation involves nervous 
apparatus is true, by all analogies, but that it is in any special sense 
a nervous phenomenon, is not true. 



MENSTRUATION 707 

Ott (Wiener medizinische Presse; Archiv fur Gynakologie) has 
shown, as have many other observers, that there are slight changes in 
temperature, pulse, blood pressure, and respiration through the men- 
strual cycle, and that, carefully followed, these indicate that vital 
activity is at a maximum just before, or during, menstruation. Gath- 
ering up the large array of facts that show these trivial changes in 
vital processes, and show, also, that the daily excretion of urea and 
of carbonic acid is subject to slight variations through the menstrual 
cycle, Stephenson has held that the wave of rising vitality is influ- 
enced by a menstrual centre, wholly hypothetical as yet, which is, or 
ought to be, situated somewhere in the lumbar portion of the spinal 
cord, and which acts rhythmically to bring on Stephenson 's wave and 
the accompanying menstrual flow. No explanation has yet been 
offered for the rhythmic action of the supposed centre. The advo- 
cates of this theory of menstruation are troubled little by the fact 
that similar waves are to be detected in the lower animals and in the 
males of our own species, and the doctrine may well be dismissed in 
the words of Stephenson, himself, who reduces the whole theory 
ad absurdum by his comment on the varying intensity of vital phe- 
nomena in the male : " it is therefore evident that the phenomena 
belong, not to the function of menstruation, but to a general law of 
vital energy." 

A case of Rushton Parker's may here be quoted with profit. He 
was consulted by a couple who had been married eight months and 
had never accomplished coitus. The husband was twent}^-four }^ears 
old, and nothing could be seen amiss with him save that he had " a 
cowed look." He denied any practice of masturbation and also denied 
any sexual feeling. All organs were normal, save that the testes were 
small and soft. His wife had observed that he had a sanguineous 
discharge for three days out of every month. He readily agreed to a 
separation and a division of income. (British Medical Journal, 
March, 1899.) 

Napier has suggested that the pressure of the enlarged utricular 
glands of the endometrial mucous membrane may be the stimulus, 
acting upon the terminal nerve filaments, to induce menstruation, and 
he has pointed out the fact that the time required for such growth in 
the constantly renewed mucous membrane, would correspond rudely 
with the intermenstrual period. 

But we need not look for any accurate, mechanical explanation of 
this function. We can do no better in the present state of our 
knowledge than accept menstruation as a habit which has been nailed 
upon our race by heredity, and which is for us an ultimate biologic 
fact. This hypothesis meets all cases of menstruation without ovula- 
tion, all cases of menstruation after the removal of the pelvic geni- 
talia and the destruction of their nervous apparatus, all cases of 
menstruation in infants and in withered old women, all cases of men- 
struation in men, and all cases of vicarious menstruation. 



708 A TEXT-BOOK OF GYNECOLOGY 

The Role of the Uterus. — It is often said, with essential truth, 
that " menstruation marks the destruction of the endometrial mucous 
membrane." If it does not do all this, it certainly marks the destruc- 
tion of its highly organized, thickened superficial part, the decidua 
menstrualis. The endometrium is a mucous membrane highly special- 
ized, to be sure, but not more so than the mucous membranes of the 
intestines and the stomach, and it certainly does not depart from the 
type so far as does the conjunctiva. It is distinguished anatomically 
by its delicate stroma and by its abundant glandular elements; it is 
distinguished physiologically by its power of self-renewal which recalls 
continually the foetal tissues, the cells of malignant growths, and the 
tissues of the Crustacea and lowlier forms of animal life. Delicate 
as it is, it is not thinner, but thicker, than most mucous membranes 
during the greater part of the menstrual month. It is essentially a 
uterine lining, for it does not extend downward into the cervix, or 
into the Fallopian tubes. At, or before, the menstrual time, it under- 
goes fatty and granular degeneration and is cast off in great part, 
and when discarded, it leaves the blood vessels in its basal substance 
unsupported. That the whole mucous membrane is discarded, is not 
believed; regeneration is accomplished by the remaining glands in 
the deeper layers, and is complete in about ten days after the general 
wreck has been effected. 

These facts have been derived from the studies of many observers, 
but unfortunately they have been somewhat vitiated by the post- 
mortem delay in preparation of specimens, or by the impress of lethal 
accident or disease. For this reason we turn to our quadrumanous 
sisters and follow the admirable epitome of Walter Heape's labours, 
prepared by Lawrence for the Ohio State Medical Society in 1897. It 
will be understood that the researches cover studies made upon the 
lowly Cynomorpha, but mostly upon the higher group of Anthropomor- 
pha which includes the lemurs, chimpanzees, orangs, and the gorilla. 

Heape divides the menstrual cycle into four stages: 1. Rest; 
2. Growth; 3. Degeneration; 4. Eecuperation. 

During rest there is only one layer of cubical columnar cells, with 
round nuclei. The protoplasm of cells is continuous with the proto- 
plasm of the stroma network beneath. This epithelium is continu- 
ous with that of the glands beneath. The stroma has round nuclei 
embedded in a continuous network of protoplasm. 

During growth the stroma nuclei are much increased by amitotic 
division and by fragmentation ; this causes swelling of the superficial 
portion of the mucosa. Nuclei now become fusiform. Deep portions 
of stroma are not changed. Interglandular tissue swells, but the 
glands are not much altered. The epithelium, lifted by the dense 
layer of nuclei, becomes less dense. The blood vessels below the epi- 
thelium undergo hyperplasia. The more superficial layers of the 
stroma swell. Glands are widened. Many stroma nuclei are re- 
duced in size, but the mucosa as a whole is increased in thickness. 



MENSTRUATION 709 

During degeneration there appears hypertrophy of the epithelium, 
the stroma, and the walls of the blood vessels. Afterward, there is 
amyloid degeneration of the superficial layers of the mucosa. In this 
layer, congested capillaries break down with extravasation. At each 
point of rupture, red and white cells are swept into the stroma. The 
extravasated blood collects in lacunas in the stroma, and these lacunae, 
extending and dissecting, lift the epithelium. At this time, the deep 
portions of the mucosa are not infiltrated, and neither red nor white 
cells are found free. Leucocytes and stroma cells degenerate; the 
epithelium shrivels; lacunae grow larger; degenerated epithelium is 
ruptured; blood is free in the uterine cavity. If, in any case, the 
lacunae surround a gland, the gland is washed away. In this later 
stage of degeneration, leucocytes increase the number of their nuclei 
but are not seen to divide. Denudation is now complete ; all the epi- 
thelium, portions of glands and sometimes whole glands, and even 
small portions of the stroma, are lost in the flood. The inner surface 
of the uterus appears ragged, with layers of masses of blood here and 
there. The deep layers of the stroma are wholly intact. 

In regeneration, the epithelium is formed anew by extension from 
the torn edges or by the transformation of the stroma cells. New 
capillaries are formed and new blood vessels. New glands are formed 
by the infolding of epithelium. Extravasated blood is absorbed. Ee- 
pair is complete ; rest is at hand. 

The Role of the Fallopian Tubes. — It is positively known by the 
dissection of women who have died by violence at different stages of 
menstruation, that the Fallopian tubes are much congested during 
menstruation and that, in most cases, at least, they are filled with 
fluid that contains blood corpuscles and epithelial cells. Eobinson, 
of Chicago, after a study of 800 tubes from operative and post-mor- 
tem cases (American Journal of Obstetrics, September, 1891), confirms 
this, and expresses his belief that the ovum is more easily preserved 
and wafted through the tube while thus filled with fluid. 

Besides what is known, it is certainly very probable that the con- 
gestion and contraction of the tube leads to its erection, and that, 
during some part of menstruation, it has a gross movement of peri- 
stalsis, while the cilia of its epithelium become active. That the 
tubes have much to do with the excitation which precipitates men- 
struation, might well be supposed from the fact that they are con- 
tinuous with the uterus, and the additional fact that they have a 
nerve supply identical with that of the fundus. Tait says that 90 
per cent of cases will not even menstruate once, after the removal of 
the tubes. 

The Role of the Ovaries. — Some have admitted the theory, wholly 
fanciful in the present state of our knowledge, that the ovary is, in 
part, a ductless gland and that its secretion, having accumulated in 
the tissues of the body to a certain saturation becomes the proper 
stimulus for menstruation. 



710 A TEXT-BOOK OF GYNECOLOGY 

Waiving this doctrine, which is capable neither of proof nor dis- 
proof, we may say that the ovary has but one function, viz., ovula- 
tion, the production of ovules whose highest destiny is to be fructi- 
fied in the Fallopian tube and developed in the uterus. 

It is a matter of regret that the term ovulation is a vague one. 
It is used, commonly, to comprise processes which cover much time, 
possibly months. We have reason to believe that it takes long for 
the young Graafian follicle to assert itself, deep in the stroma of the 
ovary, and still more time before it appears on the surface of the 
ovary as a mass of vascular loops, and yet more time before the wall 
becomes nonvascular, fatty and friable, for the escape of the ovule. 
And even then, according to the notions of some, ovulation is not 
accomplished until the Fallopian tube receives the ovule and sends it 
to the uterus. 

Making the term cover only the latter part of this long process, 
however, we put upon it a time limit of days rather than weeks, and 
come upon a wilderness of doctrines as to the relation of ovulation 
and menstruation. 

It is held by Pfliiger and his followers that menstruation is a 
result of a nervous discharge caused by the bursting of a Graafian 
follicle and the liberation of an ovule. Eaciborsky found ripe or rup- 
tured follicles in healthy and menstruating women who had met with 
sudden death, as did Leopold, also, and their opportunities for inves- 
tigation were ample. Unfortunately for the theory, they also found 
many ripe follicles unruptured. Walter Heape puzzles us by a state- 
ment that in Macacus rhesus the breeding season is strictly limited, 
but that menstruation continues regularly all the year round. Out of 
16 cases he has found a recently discharged follicle in only 1 case. He 
has not seen a clot in a follicle in any case. His researches on Semno- 
pithecus agree with these observations, and lead to a conclusion that 
ovulation and menstruation have no relation in these species. Leo- 
pold's studies were made upon twenty pairs of ovaries of women whose 
menstruation was recorded, and he could only say that rupture took 
place most frequently at menstrual periods, but might occur at any 
time. 

It is held also, by some, that the passage of the ovule through the 
Fallopian tube is the immediate stimulus for menstruation. This 
is not inherently impossible, for, as we have remarked, the nervous 
and muscular anatomy of the tubes makes them almost one with the 
menstruating organ, the uterus. But we are barred from dogma- 
tism here by our ignorance of the duration of the transit of the ovule 
through the tube, for the authorities vary in their estimate from one 
clay to eight days. 

We do not even know whether the escape of an ovule from the 
ovary and its journey to the uterus precede or follow menstruation. 
Naegele taught that the ovum could live in the newly prepared uterus 
for some time after menstruation was completed, and that, failing to 



MENSTRUATION 711 

be fertilized, it was cast off with the decidua at the next menstrua- 
tion. Loewenthal's doctrine is not far from this, for he teaches that 
the ovule always embeds itself in the endometrium and stimulates the 
formation of the decidua menstrualis; at a later date, if still unfer- 
tilized, its death brings about that congestion which ends in menstru- 
ation, though he holds all hemorrhage to be accidental and pathologic. 
(Archiv fur Gynakologie, Bd. xxiv, p. 2.) Barnes also taught that the un- 
fertilized ovum, of some considerable age, is cast off with the decidua 
menstrualis, but he conceived the plausible idea that there was habit- 
ually another ovule on the road to the uterus at the time of men- 
struation. 

This jungle of theories will not be cleared until we master funda- 
mental facts which at present are beyond us. "We need, first, to col- 
lect all the ovules which pass from a woman, but their fragility and 
their microscopical dimensions will forever forbid such investigation. 
We need, secondly, to be able to read the record of ovulation which 
is left in the corpus luteum; but Cohnstein is not alone when he de- 
clares that we have no means of estimating definitely the age of one 
of these bodies. 

We are therefore obliged to return to the principle enunciated in 
a former section, and to say that menstruation is a habit of the female 
organism, inherited and fixed beyond her present needs, and to that we 
add that ovulation may occur at any part of the menstrual period 
cycle. Avoiding any more definite creed, we are not dismayed by the 
following anomalous cases which are entirely inexplicable on other 
theories of menstruation and ovulation. 

In girlhood, and even in childhood, ovulation is active without 
menstruation, and is sometimes attested by pregnancy before the 
menses have appeared. .Robinson, of Chicago {American Journal of 
Obstetrics, September, 1891), says that an examination of 800 ovaries 
convinces him that ovulation begins before birth and continues into 
old age. 

Conception, implying ovulation, occurs in many nursing women 
who do not menstruate. 

Menstruation occurs in some exceptional women only during preg- 
nancy. 

Menstruation occurs exceptionally after the removal of the 
ovaries. 

Girls and other young mammals have ovules even at birth, long 
before the period of menstruation. 

De Sinety found a fresh corpus luteum in a young woman who had 
died of phthisis, though she had not menstruated for many months. 
Vermeil and others have reported similar cases. 

It is known that some women who have long passed the meno- 
pause, ovulate. 

In rare cases women who have ceased to menstruate become preg- 
nant. 



712 A TEXT-BOOK OF GYNECOLOGY 

The Hygiene of Menstruation. — The primitive man looked upon 
his genitalia and those of his mate with worshipful regard, first, as a 
fetish, and later, as an incarnation of the creative principle in Nature. 
Most women, and even some men with microscopes, have failed to out- 
grow this savage theology, and upon small knowledge of the genitalia 
have grafted an incredible mass of barbaric superstition and crude folk- 
lore. More or less vaguely, women hold to the belief that menstruation 
is a season of peril, and the general drift of the best teaching is to 
the erroneous opinion that menstruation is a pathologic process which 
must be skilfully guided to an end by the craft of the physician. It 
would be well if this had definite form, for then it would become vul- 
nerable and absurd; as a matter of fact it survives in misty form in 
the subliminal consciousness of the race, beyond the reach of logic or 
persuasion. 

Menstruation being a perfectly innocuous, physiologic process, it 
may be said that the hygiene of menstruation is the hygiene of all the 
year round. The woman who conserves her general health and main- 
tains herself in the highest possible vigour has done all that can be 
done to make menstruation safe and easy. 

In negation, we will say that there is no need for putting the 
young girl to bed during her first few periods, and still less excuse for 
putting a poultice on her, as a distinguished author has recommended. 
Clothing should be changed at need, in spite of the protests of old 
women; and there is never so much need of a daily sponge bath as 
during the menstrual time. The salutary truth, that filth and health 
do not agree, should be pressed upon the young girl and upon the 
older woman who complains of an ill-smelling menstrual discharge 
when, in fact, she is offensive from the rancidity and putrescence of 
axillary secretions. The fishermen's wives in Europe, the bathing 
attendants at the seashore, and the patients at water-cure establish- 
ments are not, in general, permitted to abstain from contact with 
water at the menstrual time, and they are not aware of any great 
harm resulting from the exposure. 

In the early stages of Raynaud's disease, Basedow's disease, phthi- 
sis, chlorosis, and a number of forms of anaemia, amenorrhea is an 
early symptom. In the late stages of disease, the wretched female 
patient often looks back over her career and recalls to memory some 
one of the traditional causes of suppression — a bath, a drenching, or 
what not — and with poor logic she connects the exposure, the sup- 
pression and her ruined health in a causal chain. Experience, the 
fruitful mother of all error, has its preconceived theory; it marks the 
hits; it forgets the misses; it perpetually confirms the error with 
which it began. And so it happens that the greater number of 
women are, at the menstrual time, fearful of harm when they make 
a toilet for the skin, or put the hands in cold water, or walk, or ride, 
or dance, or do a thousand things which are considered proper and 
safe during the intermenstrual period. 



MENSTRUATION" 713 

The list of complications which are said to go with menstruation 
is one which might be safely attributed to a group of men. It in- 
cludes constipation or diarrhoea, subjective sensations of heat or cold, 
increase or diminution of urine, anorexia or craving appetite, in- 
creased activity of the sudoriparous glands, pigmentation of the skin, 
yawning, cramping, hiccough, meteorism, palpitation, and irritable 
temper ! 

For a short period at the very height of menstruation, the bodily 
temperature is elevated about half a degree. In very impressionable 
persons, this causes a slight feeling of lassitude. A certain slight 
dragging sensation, a feeling of weight in the legs, and a definite 
though slight pain in the sacrum, groins, and thighs, often cause 
menstruating women to take more than their usual repose. It would 
not be wise to induce such women to exercise violently; neither, on 
the other hand, is it wise to coddle them and cultivate valetudi- 
narianism. 



CHAPTER XLYI 

THE DISORDERS OF MENSTRUATION 

Menorrhagia, general systemic causes, local causative diseases above the pelvis, 
pelvic causes ; treatment — Metrorrhagia — Amenorrhcea ; treatment — Retention 
of menses, symptoms and diagnosis ; treatment — Dysmenorrhcea ; treatment — 
Membranous dysmenorrhoea — Intermenstrual pain — Vicarious menstruation — 
The menopause. 

Menorrhagia. — Menorrhagia is an excessive flow from the nterus 
at the menstrual time. Only its periodicity distinguishes it from 
metrorrhagia. 

We can hardly conceive of hemophilia as a cause of menorrhagia. 
Women transmit this defect of constitution, but the disease is so mani- 
festly incompatible with menstruation that Nature has long since 
stamped out the tendency to hemophilia in the female. 

General Systemic Causes. — (a) In purpuric conditions we have a 
strong tendency toward menorrhagia, for in this disease the blood is 
altered in such wise that it has a manifest tendency to transudation, and 
a loss of its normal coagulability. Menstruation opens the door and 
the flow is excessive, (b) In all forms of anosmia we have a relatively 
great amount of water in the blood, a relatively diminished amount of 
albuminoid substances, and diminished coagulability. Chlorosis, in 
this regard as in many others, stands apart from the anaemias, for it 
tends to scanty flow, if any. (c) In plethora the increased flow is due 
to high arterial tension rather than to a morbid condition of the blood. 
(d) In the different chronic forms of nephritis we have an altered condi- 
tion first, of the blood, and, later, of the blood vessels, both disposing to 
hemorrhage, (e) In malarial poisoning we have the bleeding tendency 
well marked, not alone in the uterus, but also in the rectum, bladder, 
and nose. (/) In any form of debility, menstruation is apt to run into 
excessive hemorrhage from inability to promptly repair the endome- 
trium, (g) In the specific infectious diseases we have reason to believe 
that hemorrhage is often excessive by a combination of depraved blood, 
altered blood vessels, and the debility of an organism that is too busy 
with the disease to make repairs in the uterus. 

Local Diseases above the Pelvis, causing Menorrhagia. — (a) Violent 
emotion has often been known to increase the menstrual flow, even 
to the danger point. We are obliged to assume that it causes vasomotor 
714 



THE DISORDERS OF MENSTRUATION 715 

paralysis, (b) In cardiac disease with venous stasis, extravasation is 
invited. Stagnant blood, dammed back in the veins by an inefficient 
heart, seeks a place of least resistance even in the male patient. In 
the female the place is indicated plainly, once a month, (c) Pulmonary 
disease may run such a course as to obstruct the pulmonary circulation 
early, thus wearing out the right heart and leading to venous stasis. 
Ordinarily, the early course of the disease is toward amenorrhoea, or 
scanty menstruation, and the blood is rich in the coagulating prin- 
ciple, (d) In hepatic disease, the return of blood from the uterus is 
impeded, and there exists in jaundice the hemorrhagic tendency which 
is the plague of the surgeons, (e) In splenic disease, also, there is 
some obscure alteration of blood or of blood vessels disposing to hemor- 
rhage as in uraemia. All these causes of menorrhagia are rare, how- 
ever, (f) In a given number of cases of abdominal tumour we shall 
find a great number of cases of menorrhagia due to pressure of the 
great venous avenues of return of blood and to the perturbing influence 
of pressure on the uterus, (g) Yet, the commonest cause of menor- 
rhagia, after all, is the f cecal tumour so often present in the female 
patient. It, like any other abdominal tumour of its size, operates 
viciously by compressing venous trunks; it presses upon the uterus 
and directly irritates the organ; it is liable, through the sympathetic 
system, to irritate the nervous apparatus of the uterus and increase its 
arterial supply; by its downward pressure it aggravates every flexion 
and version; it slowly establishes a condition of stercoraemia and 
hydremia; it breeds a tympanitic tumour in addition to the solid 
fa?cal mass, and thus still more increases pressure. 

Pelric Causes of Menorrhagia. — But for the etiology of menor- 
rhagia, we look most to the bleeding organ itself and to its neighbours 
in the pelvis. The uterus and tubes are anatomically continuous and 
virtually inseparable by dissection. These organs and the ovaries have 
a common nervous supply. The whole trio is fed by only two pairs 
of arteries, and their veins are few and simple. It is, therefore, in- 
herently probable, and it is clinically proved, that irritation or inflam- 
mation of one of these organs must lead to exalted function of the 
other two. 

Passing to the uterus itself, we note that one of the most com- 
mon causes of menorrhagia may be found in the subinvolution of the 
v terns after abortion. Subinvolution may also occur after delivery at 
full term, especially if it is not followed by lactation. 

In the condition known as areolar hyperplasia, sometimes reck- 
oned a true chronic corporeal metritis, we have a flabby, atonic state 
of the uterus with enough inflammation to determine much blood 
to the uterus and to limit its power of repair after the menstrual 
wreck. 

Inflammation involving the endometrium tends to produce menor- 
rhagia, and this tendency is especially well marked in the cases where 
large granulations are produced on the interior surface. 



716 A TEXT-BOOK OF GYNECOLOGY 

Healed lacerations of the cervix and deep ulcerations at the same site 
sometimes seem to be starting-points for an irritation that disposes to 
an increase of menstrual blood. 

In malpositions of the uterus we have often the greatest irritation 
leading to increased blood supply. In some of the malpositions, the 
veins of the broad ligament become varicose from distortion and long- 
continued pressure. The blood returning from the small vessels of the 
endometrium passes into the uterine sinuses and thence toward the 
heart by way of the veins in the pampiniform plexus, and it is evident 
that any limitation of the carrying power of the veins of this plexus 
will produce some degree of stasis in the uterus. 

Uterine tumours also act in this double manner to cause monor- 
rhagia; they vastly increase the normal irritation of the uterus, and 
they act in a mechanical manner, by pressure or by dragging, to block 
the veins of the broad ligament. Subperitoneal tumours do less harm 
than those which lie in the wall of, or under, the endometrium. After 
incomplete abortion, when some portion of placental tissue remains 
rooted in the endometrium, the menstrual flow is sometimes enormous. 
The irritation is out of all proportion to the size of the offending 
body. Malignant disease of the uterus often leads to menorrhagia 
at an early stage. Sometimes the menorrhagia has no provoking cause 
that can be detected. The theory of congestion is then invoked to 
cover our ignorance. Eeinecke and others have, of late years, devel- 
oped the fact that in some cases of menorrhagia the uterine arteries 
are sclerosed, prematurely old, prominent, and incapable of contraction. 
They carry a maximum of blood and necessarily tend to menorrhagia. 

Treatment of Menorrhagia. — When menorrhagia is due to plethora, 
the tendency is toward automatic palliation. Later, the volume of the 
blood may be diminished by purgatives, exercise, and restricted diet. 

In all forms of hydremia, the treatment must look to restoring to 
the blood its nutrient principles and especially its saving power of 
coagulation. In the very time of menstruation, every means of limiting 
the discharge should be used; for each hemorrhage, by impoverishing 
the blood, invites a more profuse and prolonged hemorrhage. The 
bowels should be kept open without violent purgation. The subject 
should lie rather than sit. The feet should be warm, day and night. 
In urgent cases the tampon should be applied in such a manner as to 
correct any malposition of the uterus, and it should make firm pressure 
on the cervical tissues. Since it is not the object to coagulate the 
blood in the vagina, no styptic substance should be used. The tampon 
should rather be treated with some antiseptic substance like boric acid 
which is only slightly toxic, is inoffensive, and has a faint acid reaction, 
to avoid neutralizing the normal acids of the vagina. In extreme 
emergencies the uterus might well be flushed with hot water at 110° to 
115° F., under asepsis and with free return of fluid secured. The 
emergency passed, the attempt should be made to improve general nu- 
trition and to enrich the blood. The milder, scale preparations of 



THE DISORDERS OF MENSTRUATION 717 

iron have great value for prolonged use. In the presence of a brisk 
hemorrhage, the tincture of the chloride of iron is of most value. The 
common impression that iron increases an existing hemorrhage has no 
basis in fact. Arsenic is of great value in anaemia, and may well be 
alternated with iron. 

The debility which leads to menorrhagia is often based on some 
hemic defect. It will often demand a blood count and estimate of 
hemoglobin with a study of excreta for a comprehension of its causes. 

Menorrhagia complicating the acute, infectious diseases is seldom 
severe or long continued. In the exanthemata, it usually declines with 
the development of the cutaneous eruption. In scorbutus, treatment 
must be addressed chiefly to the underlying disease, and that treat- 
ment is dietetic. In menorrhagia resulting from nephritis, the 
treatment must reach the underlying disease, also. In malarial cases, 
treatment for the toxaemia will accomplish brilliant results even in an 
emergency. The chief danger in menorrhagia is that the physician will, 
with mind prepossessed, seek for a cause in the pelvic organs and 
overlook some profound disease or dyscrasia. Menorrhagia caused by 
great disturbance of the emotions should be treated by palliative meas- 
ures at first. The menorrhagia, curiously enough, tends to repeat itself 
for a few months. When this affection is a result of cardiac or of pul- 
monary disease, it needs virtually no treatment save that which is 
directed to the relief of venous stasis. In pulmonary disease, the ulti- 
mate tendency to amenorrhea will be an aid. When menorrhagia com- 
plicates hepatic, splenic, or renal disease, the treatment is mostly pal- 
liative, while the fight is made upon the causal disease. In advanced 
stages, when a cachexia has been established, menorrhagia is rarely a 
complication. The treatment of abdominal tumours is a matter of sur- 
gery, not to be considered in this chapter. The treatment of faecal 
tumours is of the greatest importance and may be here discussed. They 
should be swept out by repeated doses of purgatives. In severe cases, 
it may be necessary to aid purgatives by enemata or by tunnelling 
through hard masses in the rectum. If it is known that there is no 
obstruction, calomel may be given in an efficient dose combined with 
podophyllin, or any of the more powerful vegetable purgatives. For 
initial purging, the salines may suffice. Thev have a special value in 
their power to cause a free osmosis into the intestinal tube, reducing 
incipient inflammation and putting an end to the absorption of poisons 
from the intestine into the blood. Eepeated enemata, each measuring 
half a pint, of a saturated solution of magnesium sulphate, retained 
as long as possible, will often produce great results and save the patient 
the annoyance of large and repeated doses of medicine per os. When the 
bowel is well emptied, it is important to keep it empty to the physio- 
logical limit. Radical and abrupt changes in diet will have some effect, 
but very little, in the average woman of constipated habit. The laxa- 
tive power of fruit is a fiction from Paradise. So long as it is a 
novelty, oatmeal is sometimes an efficient laxative, but the system is 



718 A TEXT-BOOK OF GYNECOLOGY 

soon habituated to it. Mustard seed or flaxseed, swallowed without 
mastication, is oftentimes very efficient. Senna, the basis of most of 
the secret purgative and laxative teas and syrups, is to be commended 
in small doses for a limited time. As an alternate medicine, cascara 
sagrada is most excellent. The intestines rarely become habituated to 
this medicine. Atropine and strychnine seem to have some effect in 
breaking up constipation. 

It has long been taught that a sharp purgative, preferably a mer- 
curial, given a short time before menstruation, has a distinctly cura- 
tive effect in some cases. The treatment should be kept up for some 
months. It may be conceived that the benefit is accomplished by de- 
pleting pelvic viscera, diminishing a mild metritis, and exercising a 
tonic nervous action on the uterine blood vessels. 

Supposing the bowels to be in good order, one may resort to ergot 
and its allies, ustilago and gossypium, with a hope of permanently con- 
tracting the fibres of the uterus and the muscular fibres of uterine and 
ovarian arteries. The liquid preparations of these drugs are so bulky 
and offensive that tablets of ergotin are to be preferred. The treatment 
is of no avail in emergencies, but under ordinary circumstances should 
be maintained for one or two months at least. 

Excellent results will sometimes be attained by giving potassium 
iodide for ten or twelve days previous to the menstrual time. The 
dose should rise, as rapidly as tolerance will permit, from 10 to 40 
grains per diem, and be there maintained until the second day of 
menstruation. Apart from any obscure " alterant " action, the drug 
produces its benefits through known channels. It has a power of 
dilating systemic arteries and lowering arterial tension; it improves 
the nutrition of the heart, in many cases, by its direct action on 
heart muscle and by its action on the coronary arteries; it cures bron- 
chitis and bronchitic asthma and moderates the complications of em- 
physema, thereby lightening the labours of the right side of the heart 
and diminishing venous stasis; it palliates concealed syphilis. For 
prompt and evanescent action as artery dilators, alcohol and the nitrites 
may be used. Digitalis has no place in the routine treatment of menor- 
rhagia. It is only indicated in cases where the hemorrhage is caused by 
some cardiac disease demanding the drug. 

The use of styptic substances per os has no other justification than 
a credulous hope that the stomach may be induced to take up so much 
of the drug that the blood will be saturated to a degree sufficient to 
check undue hemorrhage at a distant point. Quinine, strychnine, and 
atropine, have no direct effect upon the hemorrhage, but have great 
value when it is desired to whip up circulatory or respiratory centres, 
or the lumbar centres which send fibres through the hypogastric plexus 
to the uterus and its appendages. 

In rare cases, supposed to be caused by ovarian irritation, the bro- 
mides will diminish the menstrual flow. They certainly tend in the 
main to diminish the flow, and, as Ernst, of Vienna, has pointed out, 



THE DISORDERS OF MENSTRUATION • 719 

to increase the interval between menstrual periods. Whether, for the 
benefit reached, it is well to blanket the whole nervous system with a 
depressant drug, is a question. 

Electricity has doubtless a place in the treatment of menorrhagia, 
though it will be the resource of the few. The positive pole in the 
uterus, carrying a galvanic current has an admitted hemostatic effect, 
the current being cautiously raised to from 30 to 50 milliamperes. 
Later, in the absence of hemorrhage or inflammation, the current may 
be much increased. In any case, a cure can not be expected under a 
treatment extending over months. In emergencies, the current used in 
the interior for hemostasis may be raised to 150 milliamperes, and it 
must be understood that it is then positively cauterant. Strict anti- 
septic technique must accompany this treatment. (G-oelet, New York 
Medical Record, March 28, 1891.) 

Desperate cases of menorrhagia may require the induction of the 
artificial menopause by the aid of the surgeon. 

Metrorrhagia. — Metrorrhagia is a hemorrhage from the uterus in 
the intermenstrual period. Time was when menorrhagia and metror- 
rhagia were a long way apart, but it is now perceived that all red fluxes 
from the uterus are essentially hemorrhages, and all akin. When we 
meet with a metrorrhagia which begins in an intermenstrual period,, 
continues with increased volume through a menstrual period, and so 
runs on for weeks, we perceive small difference between the two affec- 
tions; or, if we encounter a case of sharp menorrhagia which each 
month lingers longer through the intermenstrual period to become 
at last an unbroken flow, we must admit that our classification is 
artificial and a matter of mere words. The reader is, therefore, referred 
to the preceding section for the causes of metrorrhagia in general, since 
these uterine hemorrhages are not sharply distinguished in their 
etiology. 

Metrorrhagia in early life almost always points to anaemia, and 
particularly that anaamia which is very properly referred to sterco- 
raemia. 

In young married women, metrorrhagia should excite suspicion of 
incomplete abortion. In such cases curettage should be done after the 
technique laid down in another part of this work. The mechanical 
removal of the wreckage of an incomplete abortion has the added ad- 
vantage that it gives opportunity to remove the dilated follicles that 
maintain uterine hemorrhage in low grades of endometritis, whether 
the endometritis is a result of abortion, or not. The operation also 
clears the diagnosis by giving information of intrauterine tumours. 

In mature life, metrorrhagia, much more than menorrhagia, should 
excite suspicion of uterine cancer. Such subjects, approaching the 
menopause, look complacently upon an intercurrent flow as a sign of 
vigour or of plethora. They know that pain and fcetor belong to can- 
cer, and, having no knowledge beyond this, they pass, still in good gen- 
eral health, beyond all possibility of surgical aid. In the present state 



720 A TEXT-BOOK OF GYNECOLOGY 

of our knowledge, it would be well- if every case of metrorrhagia in 
women past thirty-five years were held to be a case of cancer until the 
contrary was proved. In the absence of a visible and tangible mass of 
malignant growth, the physician should still hold doubts as to small 
adenomata of mucous glands of the endometrium. In 2,200 cases of 
metrorrhagia, Baer found 41 who had malignant disease of the uterus. 
Only 3 of these were younger than thirty-five years; only 5 were older 
than fifty-five years; 26 of them fell in a group in the years between 
forty and fifty-five years of age. 

Metrorrhagia is sometimes maintained by a sclerosis of arteries, 
as in the case of menorrhagia. Leopold, in 1896, made 4 extirpations 
of the uterus in women who had borne from 4 to 12 children, and 
found the uterine arteries large, tortuous, thick, and gaping. The 
vessels projected above a cut section. The thickening was of the median 
layers, the intima not being affected. The extirpations were made for 
suspected malignant neoplasm. Curetting had been of no avail and 
ergot had appeared to increase the hemorrhage. 

When the floor of the pelvis has been broken down, with great 
damage to the levatores ani and to the recto-vesical fascia, metror- 
rhagia is likely to follow in the course of years, and to be so intractable 
that surgical treatment only will avail. 

The general principles of treatment laid down for- menorrhagia 
apply here. In metrorrhagia, intrauterine applications will work a 
cure in a larger proportion of cases than in menorrhagia. The cervix 
being sufficiently dilated, iodine in solution; phenol, pure, diluted, or 
combined with iodine; creosote in solution; or tannic acid, may be 
carried up to treat the entire endometrium with the hope of diminishing 
succulence or atony, or of reducing inflammation. The solution of 
these and other styptic and cauterant substances is often made in 
glycerine, and that solvent, by virtue of its great avidity for water, is 
able to deplete the endometrial tissues and new growths. 

Amenorrhcea.- — Amenorrhea is not a definite disease or even, in all 
cases, a symptom of disease. By the term is indicated merely an ab- 
sence of menstruation. Amenorrhcea may be physiologic, as in nursing 
women and in pregnant women, or it may be symptomatic of some 
wasting disease. 

An interesting group of women appear to be perfect in their devel- 
opment and yet never menstruate. Not all such women are sterile, 
though conception is excessively rare among them. Millikin has knowl- 
edge of one such case, a woman who has been happily married for 
twenty years. Hubbard Winslow Mitchell {New York Medical Record, 
March, 1892) reports an Irish immigrant, well developed as to geni- 
talia and breasts, who had never menstruated. Withrow, of Cin- 
cinnati, has reported the cases of two sisters, and the daughter of 
another sister, who had never menstruated. All three of them had en- 
joyed the sexual relation and all were sterile. Two of them had profuse 
periodical epistaxis. 



THE DISORDERS OF MENSTRUATION 721 

It would appear that this condition of amenorrhcea may be acquired, 
as in the notable case reported by Petit (Annates de gynecologic, 1883), 
in which the woman of twenty-one years was found with a child be- 
tween her thighs, an inverted uterus and an adherent placenta. Eeduc- 
tion was accomplished, and, after a tedious convalescence, she was 
restored to health in the course of eighteen months. Although she 
bore a child after two years and a half, another in sixteen months, and 
her fourth child after six years, she never menstruated and never had 
leucorrhcea. 

In most cases of lifelong amenorrhcea something teratological ap- 
pears. Thus, Walter B. Chase (American Journal of Obstetrics, No. 4, 
1898) records the case of a woman of good physical development who 
had the menstrual molimina every twenty-eight days from the age of 
eighteen; she married at twenty- two years and came under his notice 
at twenty-four years of age. She had been sterile through two years 
of married life. Her periodical pain was unbearable, and insanity was 
feared. Her abdomen was veiy fat but tumour was diagnosticated. 
Operation revealed a thin-walled sac subdivided into cavities of which 
some were, and some were not, infected, and a teratoma containing 
sebaceous matter in emulsion, hair plates, and bone. No Fallopian 
tubes were found. A small amount of ovarian tissue was flattened on 
the wall of the multilocular cyst, with an imperfect corpus luteum. 
Manton reports (American Gynecological Journal, March, 1891) a 
woman of twenty-two, married three years, who had never menstruated, 
but for four or five years had suffered, periodically, with abdominal 
cramps, severe headache, and, occasionally, tender and swollen breasts. 
She had no vagina, but the husband's perseverance had made, at the 
fossa navicularis, a pouch 3J inches deep, leading nowhere. Eectal 
examination with a sound in the bladder showed the ovaries in proper 
position, but no uterus could be found. Manton has seen a girl in a 
similar condition. She seemed to enjoy such " intercourse " as was 
possible to one who. in lieu of a vagina, had a cul-de-sac of a depth of 
only 2 inches. Herbert C. Jones, of Decatur, 111., gives an account of 
a woman of size and stature above the average, who consulted him as 
to a vaginal discharge. She had never menstruated. He found that 
she had a capacious vagina, a large, hooded clitoris, a uterus three quar- 
ters of an inch in depth, and no ovaries to be distinctly palpated. She 
had no mamma?, and her nipples were rudimentary. Her statement 
that sexual intercourse gave great pleasure was confirmed in a day or 
two when it was determined that her discharge was from gonorrhoea 
contracted the second year after marriage through illicit intercourse. 

In young girls, there is often a period of amenorrhcea following 
hard upon the first one, two, or three, menstrual periods. In most 
cases this failure is due to anaemia. 

Treatment of Amenorrhcea. — Since amenorrhcea is only a symptom, 
it can not in strictness be said to require any treatment. The treatment 
should be addressed to the diseases or dyscrasiae of which it is sympto- 
47 



722 A TEXT-BOOK OF GYNECOLOGY 

matic. The amenorrhea which comes to many young girls soon after 
menstruation announces itself, should not be meddled with. It is a 
confession that Nature's first attempts were premature. The amenor- 
rhoea of some young girls is, however, a danger signal hung out to 
give warning of the earliest stage of phthisis. The treatment of the 
symptom is wholly included in the appropriate treatment of the disease. 

Anaemia should also be suspected in well-grown girls who have 
passed the usual age of menstruation. Most cases will be found to have 
dyspepsia as the underlying condition, and the dyspepsia will gener- 
ally depend upon physical inaction, incessant nibbling without real 
meals, addiction to sugar, which, valuable as it is, will destroy the 
appetite and lead to fermentative dyspepsia as girls use it and abuse 
it. Coffee toping is a common cause of dyspepsia at this age. Whim- 
sical appetites for ice, uncooked rice, laundry starch, uncooked prunes,, 
and miscellaneous rubbish may often be detected by adroit questioning, 
and it will be found that these substances in many cases, not only dis- 
place the regular meals, but lead to a positive gastritis, the pains 
whereof are interpreted as an all-day hunger to be satisfied only by 
the trash that bred it. The subjects of these whims are often fine, 
strong girls, who will do well if they can be brought to take no food 
save at regular meals with limitations as to coffee, sweets, and raw 
fruits. An astonishing number of girls are ignorant of the fact that 
the human stomach needs long periods of profound rest; the truth 
once presented to them by authority, they will often take the reform in 
their own hands with honesty and enthusiasm. 

Constipation, or coprostasis, which in the older woman is some- 
times the source of uterine hemorrhage, in the young girl very fre- 
quently produces such a degree of anaemia as to suppress the menses. 
Many young girls are so loaded with faecal products that the breath has 
the odour of a night-cart. Here again, ignorance combines with lazi- 
ness or modesty to aggravate the condition. It is very easy to convince 
the average girl that it is a filthy and degrading deed to go about loaded 
with some pounds of excrement, and when that is done the case is half 
cured. Purgatives are not indicated in these cases. The formation 
of the syringe habit and the absolute annihilation of the rectal con- 
science is most deplorable. A course of laxatives, of which cascara is 
usually the best, combined with deep massage, rational physical exer- 
cise, and an immediate response to the rectal call, will not only get 
the bowel empty, but will go far to establish the habit of a daily 
evacuation of the bowels. Until the stercoraemia has been corrected, 
one need not attempt to correct other causes of anaemia; when the 
bowels have been unloaded, and when the digestion has been amended, 
one should settle the question of the existence of albuminuria, malaria, 
syphilis, saturnism, splenic disease, or whatever dyscrasia may pro- 
duce anaemia in young subjects. When all cases have been sifted, 
there will remain a residue of girls, and boys are not exempt, who, with- 
out apparent cause, develop the " anaemia of adolescence." 



THE DISORDERS OF MENSTRUATION 723 

For the medical treatment of this anaemia, the whole range of 
hematinic drugs may be invoked. Iron and arsenic are the chief of 
them. Manganese has acquired a reputation probably far beyond its 
deserts. 

Apiol, an amber fluid obtained from parsley seeds, has been highly 
extolled by the French as being able to produce the menstrual flow. 
It is given in doses of from half a gramme to a gramme and is said 
to be wholly innocuous. The use of oxalic acid in half-grain doses, 
given every four hours to three doses, is said to be very efficient as an 
emmenagogue, but it is admitted that toxic effects have followed such 
treatment. All emmenagogues are open to an objection that they 
merely solicit a flow which ought not to be directly solicited, and 
which is sure to appear when the physiologic conditions of men- 
struation are present. This objection applies to the old and popular 
terebinthinate emmenagogues, and to those composed chiefly of essen- 
tial oils. 

It should, indeed, be a general principle of treatment that it is not 
worth while to bring on the menses, but rather to annul, if possible, 
the morbid conditions under which they disappeared. We have already 
noted the fact that there is a tendency toward amenorrhcea in the 
presence of any notable hardship, and we shall be consulted, perhaps, 
when that hardship has passed away. Even a mere change that does 
not involve hardship, will sometimes produce amenorrhcea, as when a 
girl leaves the country and enters a factory, or vice versa. Curious cases 
are sometimes observed in which amenorrhcea develops after marriage 
and persists for some months without pregnancy; and precisely reverse 
cases are observed in which amenorrhcea comes with widowhood. 
These cases are inexplicable in the present state of our knowledge, and 
should not be rashly meddled with. 

The same principle applies to amenorrhcea developing in the course 
of exophthalmic goitre, Raynaud's disease, myxcedema, and in connec- 
tion with the sudden and grave development of fat. If we can amend 
the disease, we are likely to cure the amenorrhcea; if not, the amenor- 
rhcea can do no harm. 

Retention of Menses. — In amenorrhcea no menstrual fluid is pro- 
duced. In retention, the fluid is formed but does not manifest itself 
externally. 

For this seclusion there can be but one cause, viz., occlusion of 
the genital canal at some point. (See Malformation of the External 
Genital Organs.) The occlusion may be at the os internum, or at the 
hymen, or at any intermediate point, or at all points at once. 

When the stenosis or occlusion is congenital it may be charged to 
an arrest of development. 

Acquired stenosis of the vagina may be produced by severe inflam- 
mation after parturition, as in Battey's famous case in which the entire 
utero-vaginal canal was obliterated. It has also been produced by 
severe croupous or diphtheritic inflammation with destruction of epi- 



724 A TEXT-BOOK OF GYNECOLOGY 

thelium, and by Nature's blundering repair after burns or destruction 
of tissue by escharotics. 

Clumsy surgery has produced stenosis by amputation of the cervix, 
especially when the amputation has been done by cautery. The opera- 
tion of trachelorrhaphy has been so done as to cause stenosis of the 
cervical canal. 

One third of all cases are due to an imperforate hymen, and, as a 
rule, the obstruction is external and vaginal rather than cervical or 
uterine. 

Symptoms and Diagnosis. — Apparent amenorrhea, with the men- 
strual molimen recurring regularly, should excite suspicion of reten- 
tion. The ordinary pains of menstruation may be much exaggerated by 
the retention, so that the pelvic dragging, aching thighs, legs, and 
sacrum, the flushed face, headache, nausea and malaise, will become 
almost unendurable. 

The general symptoms of sepsis must be added after a time. 

Peritonitis may arise, either as a part of the septic process or as 
a result of expression of fluid from the Fallopian tubes. Eupture of 
the tube has occurred in rare cases. 

Bulging of the hymen will lead to a diagnosis if the obstruction 
is due to an imperforate condition of that structure. 

From the first, the confined fluid forms a tumour which, growing 
monthly, sooner or later attains palpable dimensions. If the fluid is 
confined to the uterus, the mass will be round; if a tube is involved, 
the mass will be asymmetrical. 

Pregnancy is not absolutely excluded when the hymen seems im- 
perforate or when the vagina is closed. But in retention, by using 
the bimanual method, the uterus may be found central, mobile, and 
too small for a pregnancy which has lasted as long as the amenor- 
rhea; this, of course, tends to exclude pregnancy. 

When the vagina is not available, a finger should be introduced into 
the rectum and a sound into the bladder, and in difficult cases of diag- 
nosis a finger has been introduced into the bladder also, through a 
dilated urethra. 

Solid and cystic tumours arising from the genitalia are diagnosti- 
cated by the passage of the uterine sound and by the history of the case. 

Hematocele is diagnosticated by a history of rapid development, 
often with pain and shock, and the diagnosis is confirmed by the passage 
of a sound. 

Abdominal tumours must be considered and carefully excluded by 
their location and their appropriate symptoms. 

The mass of retained fluid sometimes reaches a bulk of 4 or 5 
quarts, and by its great mass is puzzling. 

Treatment of Retention. — The only treatment is the evacuation of 
the fluid by surgical means. To leave the patient alone, invites rup- 
ture. If the rupture is through the hymen it invites sepsis. Rup- 
ture through a Fallopian tube or rupture of the uterus would be dis- 



THE DISORDERS OF MENSTRUATION 725 

astrous. Emmet is singular in saying that in this affection the uterus 
becomes thickened as in pregnancy; most reporters have found its 
walls thinned. 

The patient to whom relief is not given surgically, suffers from pres- 
sure on pelvic viscera. The disturbance of the general health is very 
great. The fluid can not be absorbed, but, on the contrary, its mass 
continually grows greater. 

The question of how much fluid should be drawn off, has agitated 
the surgeons for a long time. Emmet, following Dupuytren, drew it 
all off at once, and flushed all accessible genitalia with hot water until 
they were cleansed. It must be remembered that the fluid has only 
the colour of blood and lacks its antiseptic qualities, and that fact 
alone seems to justify the bold and complete operation. Puncture of 
the protruding hymen is a trifling operation, but the surgical tech^ 
nique should be as perfectly aseptic, and possibly antiseptic, as in the 
most formidable operations. One or more points of occlusion in the 
vagina may need to be torn open. Extreme care will be demanded 
in such a dissection, to avoid opening the bladder, rectum, or peri- 
toneal cavity. Natural lines must be followed, not only to avoid 
these accidents, but to leave the greatest possible amount of epi- 
thelium on the raw surfaces. It has been found possible to make a 
vagina where there had been absolute atresia, the lumen being main- 
tained by the prolonged wearing of a glass or rubber plug, and preg- 
nancy and parturition have ensued. 

Puncture or incision of the external os, the cervical canal, or the 
region of the inner os, should be done upon the same guiding prin- 
ciples. 

In rare cases in which there was no uterus, but where fluid had 
accumulated from tubal menstruation, Braxton-Hicks and Haffner 
removed tubes and ovaries at a single operation by abdominal section. 

Dysmenorrhcea. — Some rare cases of dysmenorrhea, or painful men- 
struation, appear to be a manifestation of a general neuralgic tend- 
ency due to general neurasthenia. The very wide distribution of the 
pain — abdominal, sacral, and crural — suggests to the mind the theory 
of a general nerve storm, and it is upon this theory we rest when we 
can find no deformity or disease in the uterus or its appendages. We 
recall the anatomic facts that the nerve supply of the pelvic genitalia 
of woman is from the second, third, and fourth, sacral nerves ; that 
the sympathetic fibres come from plexuses which are virtually branches 
of the aortic plexus, and that the aortic plexus is virtually a derivative 
from the semilunar ganglion and renal plexus on each side. The 
genitalia are therefore connected by no remote strands with the cere- 
bro-spinal system and with all abdominal viscera, so that no great 
perturbation of the nervous system can occur without a disturbance of 
the genitalia. For pelvic pain at a menstrual time, bred by starving 
or irritated nerves in some remote part of the nervous system, the 
term dysmenorrhcea is inappropriate, for it does not appear that the 



726 A TEXT-BOOK OF GYNECOLOGY 

pain is due to menstruation. Menorrhagia, proposed by Massey, is 
commendable in that it asserts pain, and nothing more. 

By far the greater number of cases are due to some morbid condi- 
tion of the generative organs. Turning to the uterus, we note, first, 
that the infantile uterus, with a depth of 2 inches or less, a conical 
cervix, and a pinhole os, is often a painful uterus at the menstrual 
time. The only explanation offered for dysmenorrhea associated 
with the infantile uterus is, that the filaments of spinal nerves im- 
prisoned in the embryonic stroma of the imperfect endometrium are 
compressed during the menstrual congestion and subsequent changes. 

After pregnancy, when the uterus normally shrinks from pounds 
to ounces, the involution sometimes passes all bounds and leaves the 
patient with what is, to all intents and purposes, essentially an infan- 
tile uterus, by superinvolution. Here, again, we have dysmenorrhea, 
and are again tempted to theorize as to the replacement of muscle by 
fibrous tissue and the incarceration of nerve endings. 

There has long been a tendency to ascribe menstrual pain to the 
pressure of fluid which, by reason of partial stenosis at the inner or 
outer os, or at some point of flexure of the uterus, has an imperfect 
exit from the uterus and induces pain by hydraulic pressure. The 
old masters had high controversy on this head. Hewitt said, " The 
large majority of cases are really cases of retention/' Sims said, 
" There can be no dysmenorrhea, properly speaking, if the cervical 
canal be straight and large enough to permit a free passage of men- 
strual blood." The curative effects of cutting and stretching opera- 
tions and the similar effect of parturition were held to confirm this 
doctrine. But, per contra, Matthews Duncan was prompt to contend 
that dysmenorrhea was always neurotic in its origin; he pointed out 
that the pin-point os was large enough, as could be demonstrated on 
thousands of women ; he urged that, in the absolute retention of 
menses, the pain was no greater than it was in many cases of dysmen- 
orrhea with free exit; he held it to be significant that girls in their 
first menstruation did not usually suffer much; he showed that the 
women who suffered most had less flow than others ; he demanded an 
explanation of the fact that there was no distention or sacculation 
above the alleged stenosis. Others re-enforced him, declaiming that 
dilatation of the cervical regions cured dysmenorrhea, only because 
the irritable fibres at that point were destroyed or paralyzed inci- 
dentally during the operation or during parturition. It was also 
shown that the uterine sound passed easily into the cavity during 
menstruation; that autopsies never showed stenosis at the site of a 
flexion; that the anguish was not extreme when in membranous dys- 
menorrhea the membrane acted as a valve, temporarily, and arrested 
the flow. Confirming this negative argument came Handfield-Jones 
who declared that the os was normally open during menstruation, that 
it slowly closed in the next week and was tightly closed in the week 
before menstruation. He ascribed dysmenorrhea to fibroid thicken- 



THE DISORDERS OF MENSTRUATION 



727 



ing, hyperesthesia, and muscular spasm at the inner os. Williams, of 
Cardiff (British Medical Journal, October 24c, 189?), extended these 
views in part to the higher regions of the uterus and suggested that 
the pain of dysmenorrhea might be caused by abnormal contractions 
set up by diseased mucous membrane at the site of flexure. 

Those who hold out for the obstruction theory admit that in flex- 
ion of the uterus there may be no stenosis demonstrable in the post- 
mortem specimen, but hold that, with the ante-mortem thickening and 
congestion, there may be a decided obstruction in life which no au- 
topsy can reveal. The observation of Da Costa (Obstetrical Society of 
Philadelphia, December 5, 1889), that a flexion with a regular curve 
rarely causes obstruction, whereas a sharp bend does produce obstruc- 
tion, is important in this connection. 

Waiving all questions of the causal relation of obstruction, it must 
be admitted that a vast majority of cases of dysmenorrhcea are asso- 
ciated with anteflexion. It is very probable that this deformity is 
caused chiefly by an arrest of development in the anterior wall of the 
uterus, and a portion of the pain of menstruation may be due to 
causes which produce dysmenorrhcea in the infantile, or undeveloped, 
uterus. 

Displacements of the uterus are associated with dysmenorrhcea, 
but not so frequently as flexions. It is a question whether the pain 
is produced by direct dragging on nerves or by an interference with 
the circulation at a critical time, or by setting up inflammation in the 
uterus or its appendages with adhesions. 

Uterine tumours produce dysmenorrhoea. The general rule is that 
the more peripheral tumours, as subperitoneal fibroids, set up less 
disturbance than those which lie nearer the endometrium. 

Metritis and endometritis are common causes of dysmenorrhcea. 
In its normal condition, the endometrium is almost, if not quite, as 
insensible as the cartilages and serous membranes, but, like these 
structures, it becomes exquisitely sensitive when inflamed. There is, 
in health, a certain sensitiveness at the internal os, giving the 
patient, usually, some uneasiness, or exciting strong reflexes when 
the sound is passed over this region : in inflammation, this sen- 
sitiveness is exalted into a capacity for excruciating agony at a 
touch. Metritis and endometritis interfere with every step in men- 
struation : from the beginning they cause pressure on pelvic vessels 
and nerves; the capillaries in the deep stroma become excessively 
congested and prematurely tear the epithelium away ; the inflamed 
glands crowd and compress each other and retard amyloid or hyaline 
degeneration: and hyperplasia welds the deep and superficial stroma 
beyond the possibility of normal degeneration or regeneration. With 
all this irritation, we can not doubt that the uterine ganglia will 
become irritated, setting up contractions of muscular fibre which 
shall be either wholly abnormal or preternatural as to intensity. 
Handfield-Jones and others have shown the probability that there is 



728 A TEXT-BOOK OF GYNECOLOGY 

in all cases of menstruation a certain initial dilatation of the inner os r 
as at the beginning of labour before pressure or active dilatation has 
begun; if we grant this, we shall doubtless have the intermittent 
pains of the softening process aggravated many fold by the metritis 
or endometritis. 

The connection of tubal disease or deformity with dysmenorrhea 
is based upon very strong probabilities. The evidence is chiefly that 
the tubes are muscular; that they have motor ganglia capable of causing 
rhythmic motion in the tubes even after their severance from the 
body; that dysmenorrhea is common among women who have sal- 
pingitis; that it is intense when a tube is obstructed at the uterine 
junction; that the tubes are continuous with the uterus and have the 
same nervous and vascular supply; and that they participate actively in 
normal menstruation. 

Dysmenorrhea from oophoritis is wholly denied by some who say 
that the pain is merely referred to the ovary by the sufferer, when, in 
fact, it originates elsewhere. Nevertheless, there are very competent 
observers who have blamed certain severe cases of dysmenorrhea on 
the ovary by a process of exclusion. Dysmenorrhea is sometimes 
found to be associated with large, painful, easily palpated ovaries, 
so irritable that pressure upon them causes pain and nausea. 

The study of chronic alcoholism in the female is sometimes con- 
firmatory of the doctrine that inflammation of the ovaries may pro- 
duce dysmenorrhea; for dysmenorrhea is often set up in heavy 
drinkers as a new symptom about the time the ovaries become large 
and tender. 

Treatment. — No hope of relief for dysmenorrhea caused by an 
infantile uterus could be extended if the uterus were not unique 
among the adult tissues in its marvellous degeneration and regenera- 
tion. It has happened repeatedly that that which has been correctly 
diagnosticated as a shallow, imperfect, undeveloped uterus, has be- 
come gravid and, mayhap, after repeated abortions, has been able to 
carry a fetus to full term, and thereafter, reconstructed by normal invo- 
lution, has maintained its proper adult condition. Only a few cases 
have this fortunate termination, and the prognosis is more gloomy 
in cases of superinvolution occurring in women of somewhat mature 
years. 

The surgical treatment of uterine flexions is so treated in an 
appropriate part of this work, that its discussion as curative of dys- 
menorrhea may be omitted here. But assuming that the flexions of 
the uterus are caused by defective development, one might well look 
to the hygiene of the adolescent girl as a prophylactic against the 
deformity. It is not going too far to say that the conventionalities 
of refined European and American life directly tend to undeveloped 
genitals in the young girl. The contrast between what is decent and 
proper among girls of our time and tribe, and girls living under sav- 
age conditions, is very great. The little children in many tribes of 



THE DISORDERS OF MENSTRUATION 729 

savages are encouraged to attempt and to practise copulation until 
puberty, when, except among the most degraded, the girls are with- 
drawn from such possibilities. In many Oriental countries the girls 
are not only pledged in marriage in babyhood, but they are actually 
delivered over to their spouses before puberty. This is a very wide 
usage, also, among savages ; it has been a source of horror and dismay 
to our red men that the girls sent to Government schools menstruated 
while at school, and the basis of this rage and astonishment is the 
Indian's conviction that menstruation at school is a sure sign that his 
little children have been debauched ; for, so early do Indian girls enter 
into the marriage relation, that, as a rule, they do not menstruate 
until some time after they have found a place in the husband's lodge. 
Practices so repugnant to our notions of decency and morality seem 
most unnatural, and yet they belong to a state of Nature, and, what- 
ever may be the decrees of fashion and civilization, there can be no 
doubt that the early sexual life, arousing rather than dwarfing the 
prophetic sexual instincts of girls, tends to develop the uterus. The 
free and licentious conversation of pastoral life, and even of agricul- 
tural life, in some countries, is doubtless a stimulant in the same 
direction, and these stimulants are forever withdrawn from our girls 
in the name of decency. 

This must be so; but the mischief wrought by the young girl's 
dress is remediable. When her breasts begin to bud, the young Amer- 
ican girl's shame of them is made a virtue by her mother, and while 
she cramps them up with a long and stiff corset, she jams all abdom- 
inal viscera down toward the pelvis by the same apparatus. Most 
girls say, and say truly, that the corset is not very tight ; the mischief 
is done even by moderate pressure at the wrong place and in the 
wrong direction. A short and flexible corset, loosely worn, might be 
a beneficent thing by distributing the pressure of waistbands, while 
a long corset, stiff in front if not elsewhere, is a positive injury by 
transmitting pressure downward, by increasing constipation, and by 
interfering with the circulation in the uterus and its appendages. 

The circulation in the uterus seems to be directly related to, and 
connected with, that of the lower extremities. It is the misfortune 
of the American girl that her legs are going into a state of disuse 
by reason of perfected artificial locomotion and elevators. As a mat- 
ter of uterine hygiene, and as a provocative of uterine growth, she 
should walk much. Lawn tennis should be cultivated, and other 
games of the sort. Since it involves walking, one might even say a 
good word for golf. The bicycle used without excess is admirable. 
Housework, with its infinite variety of posturing, is to be com- 
mended. Horticulture, with its carrying and stooping and rising, is 
an ideal pursuit. Gymnastics might be scientifically prescribed for 
the legs and the whole body, but there was never yet a girl who, in 
dreary solitude, would practise bodily movements for the sake of 
exemption from vague and half-guessed pains in the far future, and, 



730 A TEXT-BOOK OP GYNECOLOGY 

for that reason, girls' gymnastics must incline to games, with some- 
thing of excitement and rivalry and the exhibition of personal prowess. 

Many girls have the feet habitually cold in summer, and in winter, 
so cold and numb as to be beyond the perception of suffering. It is 
very important that this state of arterial spasm should be broken up, 
for it is, as has been suggested, directly related to deficient blood 
supply to the pelvic organs. 

When there is a marked flexion with dysmenorrhcea, the flexion 
must be dealt with on surgical principles laid down elsewhere in this 
work. 

Stenosis, when it is believed to be a cause of severe dysmenorrhcea, 
should be dilated. The treatment is indicated whether it is held 
that mere obstruction is the cause of the menstrual pain or not, for 
in the latter case we have reason to believe that the stretching pro- 
cess interrupts unnatural and pain-producing channels of nerve con- 
duction. 

Extending his observations over 2,000 cases of marked dysmenor- 
rhcea, Emmet found that about 75 per cent of them were sterile, and 
in this fact we find another reason for dilatation, for it will often 
happen that, after that operation has been thoroughly done, preg- 
nancy ensues, and this, while a positive benefit incidentally, tends to 
the cure of dysmenorrhcea. 

The choice will lie between gradual dilatation, which requires no 
anaesthesia and may be done at the consulting room, and rapid dilata- 
tion, which faces all risks of sepsis and inflammation once for all. In 
1893, Goodell reported 400 cases of rapid dilatation with hot, antisep- 
tic irrigation and gauze packing, and no untoward results, and, while 
others have not so enthusiastically advocated the operation, it is con- 
ceded that it is not a grave one. 

In the gradual dilatation of tough strictures, electricity is of much 
assistance. A sound is insulated to within 2^ inches of its tip and is 
passed into the cervix. When resistance is met with, a current of 10 
milliamperes will often cause the resistance to disappear in a few min- 
utes. The treatment is completed by a current of from 20 to 50 milli- 
amperes for five minutes only. The sound will drop out easily and 
should be replaced by a larger one at the next sitting. The sound is, 
of course, connected with the negative pole and a clay electrode with 
the positive. 

For the treatment of flexions and strictures by the cutting opera- 
tions of Simpson, Sims, Dudley and Schroder, and for the modifica- 
tion of those operations the reader is referred to the appropriate 
chapters. The treatment in all cases seeks to amend any possible 
stricture and to interrupt the channels of painful nervous reflexes. 
Eeference to other parts of this work is also made for the proper 
treatment of displacements of the uterus by tampon, pessary, or oper- 
ation on the ligaments or upon the floor of the pelvis ; for these surgi- 
cal devices may need to be invoked for the relief of dysmenorrhcea. 



THE DISORDERS OF MENSTRUATION 731 

Like reference must be made also for the appropriate treatment of 
metritis and endometritis. 

The pain of dysmenorrhea is much relieved by drugs which are 
not strictly anodyne, but rather antispasmodic. Chloral and croton 
chloral hydrate will control many cases. Some of the milder cases 
of pure neuralgic type will yield to a single sound sleep induced by 
trional or sulphonal. Sulphonal has a specially powerful sedative 
action on the lower portion of the spinal cord whence the uterus and 
its appendages receive their spinal supply. Atropine will relieve a 
certain number of cases, and seems to benefit those women most who 
never have warm feet or a blush of pink upon the general surface 
of the body. To be of use, the drug should be given in increasing 
doses for five days before menstruation, and it should be so managed 
that the face shall be flushed for one or two evenings. Most unfor- 
tunately, alcohol has a similar effect in like cases. As it breeds an 
indifference to small discomforts it is very seductive and should not 
be used. 

Amyl nitrite may be used with good effect in cases where the 
pain comes and goes in waves. A few drops may be poured on cotton 
in a wide-mouthed bottle and the patient permitted to inhale the 
volatilized drug from time to time as the pain demands. Cannabis 
in die a will mitigate the pain. Unfortunately, its anodyne effect is 
rarely produced until the patient is about to experience some disagree- 
able confusion as to time and space. Gelsemium is a drug much more 
available, yielding anodyne effects long before it produces diplopia. 
The depressant effects of the bromides, affecting the whole nervous sys- 
tem, should be borne in mind. In ordinary cases, the relief from pain 
under the bromides is too dearly purchased. Camphor yields surpris- 
ing results occasionally, but is worthless in most cases. 

Brisk eliminant treatment, with the administration of salicylates of 
sodium, ammonium and lithium, will so signally relieve certain cases 
as to reveal the gouty or rheumatic diathesis. 

In all cases, and especially in these last, acetanilide will relieve 
the pain of menstruation. It is as valuable as any of the high-priced, 
licensed and patented " coal-tar derivatives." There is no good reason 
for combining it with alkalies or with caffeine, as in the popular secret 
mixtures. Like its chemical cousins, it is directly depressant and ulti- 
mately destructive to the most important elements of the blood or 
probably to the tissues, and its anodyne effect is produced by paralysis of 
nerve-endings. That it is a poison in all doses should be remembered, 
and it should only be used as a makeshift, or as antagonizing the rheu- 
matic poisons. It is distinctly contraindicated in ansemic or debilitated 
patients. Cyanosis, sweating, and dark urine, show overdosing. 

As an anodyne, an antispasmodic, and remotely as a hypnotic, 
morphine is an ideal drug in the treatment of dysmenorrhoea. Its 
deleterious effects upon the digestive tube are such that it should be 
reserved for emergencies. Mne out of ten female morphine habitues 



732 



A TEXT-BOOK OF GYNECOLOGY 



have learned to use this seductive poison from its employment originally 
in the treatment of dysmenorrhea. The physician who uses it should 
never name the drug in the presence of the patient, and the possibility 
of having a prescription refilled should be wholly forestalled. The 
active treatment of anaemia and chlorosis in the intermenstrual period 
will be the best treatment for dysmenorrhea in many cases which 
have no pelvic disease or defect. 

Fermentative dyspepsia is relatively common among dysmenor- 
rheas. It is sometimes necessary to treat this complication most 
actively. Active purgation just before menstruation has more than a 
palliative effect on dysmenorrhea in some cases: it reduces pelvic con- 
gestion, and possibly assists in ridding the system of poisons which tend 
to neuralgia. Heat is an admirable palliative. Patients will usually 
suffer less when rolled up in a superfluity of blankets. Hot footbaths 
and sitz baths give an amount of relief which freshly shows the patient 
that congestion and pelvic pain are linked together. Great comfort 
is oftentimes obtained by chasing the sharpest pain from the sacrum to 
the abdomen, and back again, by the application of a bag of hot water. 
Membranous Dysmenorrhea. — In some cases of dysmenorrhea the 
pain seems to be intimately associated with the appearance of a mem- 
brane in the form of a three-cornered pocket (Fig. 298), or of shreds 

and patches. In a very few 
cases the membrane gives a 
copy of the cervical canal. 
Some authors have held 
the membrane to be the re- 
sult of a slight exaggeration 
of the normal process of 
shedding of epithelium ; 
others hold it to be an ex- 
foliation of the entire mu- 
cous membrane instead of 
its superficial layer; others 
see in it the plastic lymph 
of metritis organized; 
others, with less charity for 
unmarried patients, hold it 
to be the decidua vera of a 
pregnancy which has come 
to an early termination. 

And there is a similar 
disagreement as to the im- 
mediate cause of the pro- 
duction of this membrane. 
Literature shows that it may be due respectively to flexions, versions, 
an os too small or too large, a constricted cervical canal, a constricted 
internal os, congestion of the mucous membrane, hypertrophy of the 




Fig. 298. — " A membrane in the form of a three- 
cornered pocket." — Millikin. 



THE DISORDERS OP MENSTRUATION 733 

mucous membrane, hypertrophy of the uterus, metrorrhagia, disease 
of the ovary, anaemia, chlorosis, syphilis, and hysteria. Nevertheless 
many of the subjects of the affection are exceedingly healthy women 
and some of them menstruate with so little pain as to make the term 
dysmenorrhea inapplicable. 

In the present state of our knowledge, it is safe to say that the 
characteristic exuviae are the product of an endometritis of low grade. 
The membrane does not differ in any appreciable degree from that 
which is sometimes thrown off in cases of acute phosphorus poisoning, 
in typhus fever, and in cholera. It has been precisely imitated by 
severely cauterizing the interior of the uterus, for, following that pro- 
cedure, there has sometimes appeared a three-cornered sac consisting 
of fibrous tissue " faced with a mosaic of cylinder epithelium." 
Schonheimer has had the opportunity of studying the membranes 
cast off by a woman who was sterile and had one thick tube, and he 
found nothing notable except fibrinous deposit full of leucocytes and 
uterine epithelium. In this case dilatation and curettage brought away 
normal endometrium. 

Membranous dysmenorrhcea usually appears in early menstrual life. 
It may, however, appear later, to the dismay of the patient. Cook 
(Chicago Medical Observer, February, 1898) reports the case of a single 
woman, thirty-five years of age, who had often passed shreds of mem- 
brane, but who came under suspicion of pregnancy by passing a com- 
plete cast of the interior of the uterus while visiting. Under his ob- 
servation she passed similar casts for two successive months. In 
Schonheimer's second case, the woman had borne six children without 
anything anomalous in her menstruation. After bearing these children 
she began to pass a uterine cast without pain at every third period. 

The affection sometimes disappears as abruptly. Coughlin (New 
York Medical Journal, December 9, 1899) records the case of a virgin, 
thirty-one years of age, who passed the characteristic membrane with 
great suffering. She was under observation afterward for some time 
and had no recurrence. 

The affection is exceedingly rare. Kleinwaechter made a collection 
of all accessible reports of cases and could only find 80 cases recorded 
(Wiener Klinih, February, 1885). 

The membrane is seldom passed at a first menstruation. It is most 
common between twenty and thirty years of age. Nearly 80 per cent 
of cases recorded occur in married women. Eelative sterility belongs 
to the disease; only 9.5 per cent of the cases in married women become 
pregnant. Pregnancy does not appear to be curative in any degree. 

The symptomatology of membranous dysmenorrhcea is simply pain 
and the appearance of the membrane. The pain is not always severe, 
nor is it always promptly relieved by the appearance of the membrane. 
The flow is preternaturally great, though there are exceptions to this 
rule. The increased flow is explained by the facts, that there is a 
large surface suddenly denuded, and that the membrane, as soon as it 



734 A TEXT-BOOK OF GYNECOLOGY 

becomes a foreign body, acts as a stimulant and irritant to the 
uterus. 

When membranous dysmenorrhcea has no history it will require a 
microscopic investigation to exclude abortion from the possibilities. 
After the affection has continued for some months, abortion is certainly 
excluded. Nevertheless there are some sterile women who, between 
shame and hope, will tell of 12 and 13 abortions in a year. 

The treatment of membranous dysmenorrhcea by divulsion has not 
been satisfactory. Here and there, a nulliparous patient who passes 
large membranes, has received benefit. The curette usually brings 
away normal endometrium, and makes no impression on the next men- 
struation. Strong applications of phenol, iodine, nitrate of silver, caustic 
potash and nitric acid have been used with a vague hope of reconstitut- 
ing the endometrium for the better; but it has been altered not a whit. 
Cauterant applications of electricity have not succeeded better. Gun- 
ning (American Journal of Obstetrics, April, 1891) reports a softening 
and disintegration of the membrane after a series of treatments by 
mild currents of galvanic electricity. He places the negative pole at 
the fundus and the positive pole just within the external os. His first 
current is as light as 5 milliamperes. After a few seances the current 
is raised to 10 milliamperes continued for five minutes and repeated 
every three days. 

Intermenstrual Pain. — Intermenstrual pain is here considered be- 
cause it has its relations to the menstrual period. Coming between 
the periods it certainly can not, in strictness, be allied to dysmenor- 
rhcea. 

Intermenstrual pain is referred almost invariably to one ovarian 
region or the other. In some patients, the pain changes from one side 
to the other from month to month. If there is an overflow of pain 
from the ovarian region, the iliac fossa, groin, and thigh, are affected. 
Sacral pain is not characteristic of this affection. No change of pos- 
ture will alter the character or amount of the pain. The pain is dis- 
tinctly paroxysmal and intermittent in character. The attacks are 
brief, lasting two, three, or four days, in most cases. Fever is not 
observed. 

As to the time of attack, each case is a law unto itself. Palmer 
(American Journal of Obstetrics, 1892) reports a case in which the pain 
came on four days and a half after the cessation of menstruation, but 
this is unusual. In his second case, the pain appeared about eight days 
after the cessation, and in his third case, about eleven days after. Wil- 
liam 0. Priestley gives two cases in which the pain came on fourteen 
days before menstruation. Thomas and Munde give cases in which the 
pain appeared at nine, ten, and seven, days after menstruation ceased. 
Some reporters vaguely speak of attacks covering four or five days in 
the middle of the intermenstrual period. One of Parmer's patients 
began to have the intermenstrual pain after confinement. She suffered 
ten years, then had an abortion followed by severe pelvic inflammation, 



THE DISORDERS OF MENSTRUATION 735 

then, after a slow recovery, experienced some relief, the attacks becom- 
ing milder, shorter, and less frequent. 

No pathology has been suggested for this curious affection other 
than that which attributes the pain to an ovary which, by the slow 
changes of inflammation, has become so dense as to make the passage 
of the ovule from the deeper layers a very difficult one. By hypothesis, 
there is some definite date for each woman, at which, measured from 
the close of menstruation, active preparation for the ripening and ex- 
trusion of an egg begins. This hypothesis involves the doctrine that 
pain is produced by tension about the growing follicle, and that the 
pain ceases abruptly when the follicle finally fights its way to the 
surface of the ovary and is free to ripen and rupture. The doctrine 
harmonizes the facts, that the cases do not present much uterine dis- 
ease, that several of them at autopsy have shown dense ovaries, and 
that the patients are relatively, though not absolutely, sterile. An- 
other and more tenable theory is that the pain is caused by ovarian 
adhesions which are placed upon tension by the periodical recession 
of the menstrual blood pressure, a recession which reaches its climax 
about the middle of the intermenstrual period. 

Treatment is as inefficient as this pathology would indicate. Some 
have held that benefit was given by tampons of ichthyol and boro- 
glyceride, and the great " alteratives," iodine, arsenic, and mercury, 
given for a long time. During the paroxysms, anodynes must be used. 

Vicarious Menstruation. — If menstruation implies the casting off 
of endometrial elements, then the term vicarious menstruation can 
only be justified on the plea that it is convenient, for it certainly is 
inaccurate. The term vicarious hemorrhage has been proposed, but 
this is equally inexact in that it carries the implication that hemor- 
rhage is an essential part of menstruation instead of a mere incident. 
We therefore use the older term, vicarious menstruation, arbitrarily, as 
indicating no more than hemorrhage which appears from some part of 
the body other than the uterus and in response to the menstrual 
molimen. 

Though the cervix uteri has no part in ordinary menstruation, it 
is such a near neighbour to the uterus that we might expect it to 
be the source of vicarious discharges. Few cases are recorded. Ash- 
ton (Philadelphia Medical Bulletin, November, 1898) gives an account 
of a woman from whom he removed cancerous ovaries, whereupon she 
began to menstruate at the rate of four or five days every two weeks. 
He soon had occasion to remove the uterus close to the vaginal junction 
and closed the wound with peritoneum, whereupon she began to men- 
struate scantily from the cervix, every four or five weeks. 

The tubes have occasionally presented at fistulge in the abdominal 
wall, and in a large proportion of cases yield a red discharge at the 
time of menstrual molimen. 

In ventro-fixation of any part of the pelvic organs after operation, 
vicarious hemorrhage has occurred. Thus, in 1884, Rein showed a. 



736 A TEXT-BOOK OF GYNECOLOGY 

woman from whom he had removed an ovarian cyst and had fixed 
the pedicle in the abdominal wound. Healing had taken place 
promptly, but at one point there occurred a small slough just before 
menstruation, and from that sloughing point came blood during the 
whole catamenial period. This had occurred for three years. 

The flow does not necessarily come from mutilated genitalia, but 
may come from other parts of the body, particularly from the mucous 
membranes. The nose is the most prone to vicarious menstruation. 
Macnaughton Jones reported (Edinburgh Medical Times, October, 1897) 
a case in which there was no epistaxis but in which a baffling nasal 
ulcer was conquered only after eleven months' treatment, and during 
the greater part of this time it was much worse at the menstrual periods. 
Withrow has reported 2 cases, already cited in these pages under 
Amenorrhcea, in which there was lifelong amenorrhcea and periodical 
epistaxis. 

Periodical hemorrhage from the stomach has been diagnosticated as 
symptomatic of an ulcer at its onset. Charles T. Parks, of Chicago, 
reports a curious case of a woman who was sick for eighteen months, 
and for four months had defecated at intervals of from one to four 
weeks. For two months after coming under observation she failed to 
menstruate, and at the proper menstrual times she vomited torrents of 
blood. Her mental and physical condition became so bad that when 
faecal vomiting came on, an exploratory incision was made. Enlarged 
ovaries were removed. Scybala in enormous quantity were expelled. 
The urine, which for four months had been reduced to one ounce per 
diem, rose to normal amount and recovery ensued. 

Hemoptysis is sometimes due to the menstrual excitement. Nor- 
ton (American Journal of Obstetrics, February, 1892) tells of a woman 
who menstruated from the age of fourteen, with much pain and cramps. 
At the very first menstruation she had a smothered or choking sensa- 
tion followed by a coughing paroxysm during which she spat blood 
freely. This was repeated after a few hours and so continued until the 
fourth day, when the vaginal discharge was growing pink. From this 
time the bloody expectoration diminished to the vanishing point on 
the fifth or sixth day. She had a small uterus, high in the pelvis, with 
a minute os. Nevertheless, she became pregnant after five years of 
married life and, during her pregnancy, she continued to menstruate 
after her fashion, with vaginal discharge and bloody expectoration. 
The last menstruation was about ten days before delivery. During all 
the years that she was under observation she was a hysteric. Chad- 
bourne (Journal of the American Medical Association, January 22, 1898) 
has made the important observation that many girls who have periodic 
hemoptysis, either synchronous with menstruation or replacing it, have 
incipient phthisis. 

Sometimes the hemorrhage is from the ear. Lermoyez (Societe 
medicate des hopitaux) reported the case of a girl who had a periodic 
discharge of noncoagulable blood from the right ear. After three years 



THE DISORDERS OF MENSTRUATION 737 

of this vicarious discharge, normal menstruation was established, 
whereupon the aural discharge appeared only once in two or three 
months. 

Sometimes the weak point is found at a ngevus. Bloom (Archives 
of Pediatrics, September, 1897) records the case of a girl, sixteen years 
of age, who bled from a naevus of the face. The hemorrhage came 
always two days before menstruation and lasted until the end. After 
two weeks there was another slight bleeding. Two teatlike projections 
furnished the blood. One of these being ligated, another appeared at 
the same site. 

Many cases of bleeding cicatrices have been reported. Ker- 
ley presented to the New York Academy of Medicine, November 
18, 1891, an Irish girl twenty-five years of age. At the beginning of 
her menstrual career at the age of fifteen, she developed an abscess 
at the level of the cricoid on the left side. From this point there had 
been a discharge of bloody pus four days out of every twenty-eight 
through the whole ten years. In each intermenstrual period the cicatrix 
healed. 

Vicarious hemorrhage is most common from the nose. Next in 
order of susceptibility come the stomach and intestines. The hemor- 
rhage has been observed to appear in the retina and under the con- 
junctiva. The vocal cords, the nipples, and the bladder, have also 
been the seat of vicarious bleeding. We have no philosophy for this 
remarkable phenomenon, save the doctrine repeatedly expressed in this 
chapter that the human organism has inherited, and has intensified, 
•a strong tendency to hemorrhage at the menstrual time. So strong is 
the impulse that it is felt at remote points in rare cases. We can not 
rest upon mere increase of arterial tension, for though there is a slight 
increase of tension at the menstrual period, it is so slight that it be- 
comes as naught when compared with other variations of blood pres- 
sure. A case reported to the Indian Medical Record by J. R. Wallace 
is instructive in this connection, for it indicates that Nature sometimes 
blindlv confuses two discharges under the stimulation of the menstrual 
molimen. The subject was an Anglo-Indian lady who menstruated at 
twelve years and was married at twenty-three. She proved to be sexu- 
ally impotent, incapable of orgasm, and, after enduring eight months 
of frigidity, her husband parted from her in disgust. Upon this ensued 
six years of amenorrhea, but during these years, at regular menstrual 
intervals, her breasts would become hard and painful, and milk would 
pour from them freely. She had good general health and no pelvic 
pain. She laid on an immense amount of fat, increasing her weight 
from 98 to 245 pounds. At the end of this period of six years, Wal- 
lace adjusted an intrauterine stem and a slight discharge of blood was 
noted for three days. Four weeks later she had high fever, turgid 
breasts and resumed normal menstruation, and, at the time of the re- 
port, she had so continued to menstruate for six months. During this 
last period the mammar}^ engorgement had diminished, and she had lost 
48 



738 A TEXT-BOOK OF GYNECOLOGY 

28 pounds. It would appear that the brief irritation of the uterine 
stem had determined the direction of overflow for this singular 
case. 

The Menopause. — The menopause, or the cessation of the menses, 
is an incident in the grand climacteric which comes to men and women 
alike, but comes to women earlier as a penalty for their earlier ma- 
turity. There need be no mystery as to its causes; when the geni- 
talia have reached an age approximating half a century, it is proper 
I that they should be subject to senile changes. When we consider the 

profound changes in skin, hair, arteries, Peyers patches, the intes- 
tinal villi, and crystalline lens, at this time of life we are prepared to 
admit that the ovaries may be developing fibrous tissue and may be 
losing the power of producing ovules, and that the uterus, with its 
diminishing possibilities of gravidity, is also undergoing atrophic 
changes which are truly senile. 

Making a mystery where there is none, some have assumed that 
during the menstrual years the ovaries secrete a certain substance 
which determines the menstrual flux and ministers to female health. 
Napier and Christopher Martin have held that this hypothetical sub- 
stance being lacking at the menopause, gives rise to some of the 
symptoms of the climacteric. But it should be remembered that 
shoals of men, women, and children, live in health without active 
ovaries, or with none at all, yet have good health, and that the cli- 
macteric is not a pathologic process or the menopause a symptom. 

The vulgar rule which gives to each woman thirty years of men- 
strual life allows her too little. The menstrual career is more than 
thirty-one years. Eaciborski found that Parisian girls menstruated 
first at about the age of fourteen years and seven months, and that 
the women ceased menstruating at forty-six years and six months. 
Tilt, upon knowledge of more than a thousand cases, comes to almost 
identical figures. There is no doubt that, within the past two genera- 
tions, civilization has increased the menstrual period as it has length- 
ened life. 

When the menopause is accomplished early in life, it has some- 
times been found at necropsy that atrophy of ovaries had advanced,, 
and in some cases hard, subperitoneal fibroids have been found. 
Tumours which have a mural or submucous situation tend, in gen- 
eral, to maintain the menstruation to the age of fifty, or beyond that. 

The uterus is said to become a trifle larger and heavier at the 
beginning of the menopause. Whether this is true or not, it is cer- 
tain that the tendency is presently toward atrophy. The walls be- 
come demonstrably thinner; the cervix becomes shorter and thinner;, 
the os internum is sometimes obliterated; the uterus is smaller in all 
dimensions; the endometrial glands become smaller, and their num- 
bers diminish. 

The rule is that the uterus atrophies later than the tubes and 
ovaries. A competent observer has found the ovaries of normal size 



THE DISORDERS OF MENSTRUATION 



739 



three years after the menopause, and it is known that ovulation is 
often prolonged for years after the uterus has ceased its functions. 

Changes in the ovaries at the time of the menopause have been 
studied by Otroschkevitch (Vratch), who has come to the following 
conclusion : 

" The lessening of both ovaries in old age arises in connection with 
increased growth of fibrous connective tissue and the predominance 
of this over the degenerating follicles. The disappearance of the 
epithelium covering the surface of the ovaries which occurs in old 
age can not always be put down to separation during preparation of 
microscopical specimens, but must rather be taken as one of the true 
changes in the senile ovaries. Desiccation of mature and wholesale 
degeneration of the primordial follicles forms one of the chief and 
most important changes in senile ovaries. Hyaline degeneration of 
the arteries and fibrous tissue progresses with age, and in very ad- 
vanced age striking examples of this degeneration are found. Fatty 
degeneration of the cellular skeleton occurs fairly often, and is evi- 
dently dependent upon the deficient nutrition of the ovary. A direct 
connection between degeneration of the vessels and diminution in 
function of the ovaries is not substantiated, for the ovary becomes 
limited in function when there are still but few vessels affected by 
degeneration and therefore at a time when its nutrition is but little 
altered. The nervous system plays the chief part in the complex 
process." 

At the menopause, women, like men at a corresponding age, suffer 
from a deposit of fat which is oftentimes a serious burden. The 
masses deposited in the abdominal wall and in the omentum are 
absorbed in great degree in later life, or, as some think, are simply 
redistributed. The mesentery, also, takes on a large amount of fat. 
About the heart, in the pericardium, and in the subpericardial con- 
nective tissue, the accumulation of fat becomes very embarrassing, 
leading to such serious symptoms as hurried respiration, cardiac 
asthma, cardiac palpitation, venous stasis, and, in the worst cases, to 
albuminuria and cedematous feet and legs. 

About one woman in ten will be annoyed while at the menopause, 
by flashes of heat running over the face and neck, and sometimes 
sweeping over the whole body. The heat is a subjective sensation and 
is not real. The sensation is caused by a temporary vasomotor paral- 
ysis which permits the extreme dilatation of the small vessels. Some- 
times profuse sweating follows these waves. 

Metrorrhagia lias no place among the normal phenomena of the 
menopause. It occurs rarely, though the folklore of the women keeps 
them dreaming of torrents of blood at the change of life. Scanzoni 
himself endeavoured to explain the profuse hemorrhages of the meno- 
pause by assuming a great friability of the blood vessels, and Ivisch 
has taught that the softening and relaxation of the uterine substance 
is the cause. But, as a matter of fact, their theories are superfluous, 



740 A TEXT-BOOK OF GYNECOLOGY 

for hemorrhage is not an incident pertaining to the menopanse. 
Metrorrhagia, when it does occnr at that time of life, is nsnally in- 
duced by some one of the ordinary causes which we have enumerated 
elsewhere. Baer (American Journal of Obstetrics, May, 1884) has 
analyzed 2,200 cases of metrorrhagia, and shows that the profuse 
hemorrhage belongs to the early years of greatest fecundity and to 
any period of menstrual life rather than to the menopause. In five 
years following the age of twenty-nine there were 364 cases; in five 
years following the age of thirty-four, 333 cases; in five years fol- 
lowing the age of thirty-nine, 223 cases; in five years following 
forty-four years, 131 cases. In the years between twenty and 
forty there were 1,533 cases, and there were only 66H cases for all 
other ages. 

It is at the menopause that inhibition fails and lurking cancer 
advances by leaps. Any metrorrhagia at this time of life should 
excite suspicion of cancer. A serous discharge is sometimes the 
warning of cancer, and sometimes of senile endometritis. 

With the atrophy of the hypogastric plexus come some disturb- 
ances of the sympathetic nervous system, though the reflex disturb- 
ances of the stomach and intestines at the menopause have certainly 
been exaggerated in medical literature. The dyspepsia of this time 
of life is not peculiar to females. Many alert practitioners have 
worked through a lifetime without seeing the alleged diarrhoea of the 
change of life. 

The heart is more disturbed at this time than, perhaps, any other or- 
gan. By far the larger number of cases of tachycardia in women appear 
at the very first announcement of the menopause. It is a noticeable 
fact that tachycardia is most likely to afflict those who experience the 
menopause early in life. Few cases have come to autopsy, but those 
few have almost invariably confirmed the theory that the tachycardia 
belongs to the exceptional cases in which there is early shrivelling 
of the ovaries with hyperplasia of connective tissue, and it is a part 
of the theory that the nervous reflex, doubtless a stimulation of the 
accelerators, proceeds from the cirrhotic ovaries. Tachycardia is also 
common in cases in which the operations on pelvic organs have caused 
adhesions. Tachycardia should be carefully distinguished by the 
strong, full, regular pulse, the irritable disposition, the throbbing 
aorta, the constriction of the chest, and the high percentage of hemo- 
globin, from the weak heart, announced by a weak and fluttering, 
easily compressible pulse, and the low ratio of hemoglobin which 
accompanies this sort of debility. 

Glycosuria is sometimes present in the years about the menopause. 
The prognosis is not so grave in these cases as in glycosuria in gen- 
eral, for the theory of causation permits us to believe that the disease 
is produced by irritation of the sympathetic supply of the liver, and 
permits us to hope that when the immediate nervous irritation from 
ovaries and uterus shall have ceased by atrophy, there will be a tend- 



THE DISORDERS OP MENSTRUATION 741 

ency toward recovery. In many of these cases of glycosuria, vulvar 
pruritus is the danger signal. 

Early in the menopause there is sometimes noticed a curious men- 
tal exaltation. While it lasts the woman becomes inclined, perhaps, 
to meddle with business affairs which concerned her not in earlier 
life; she has large plans; she essays large tasks; she proposes for 
herself all that is difficult or impossible. It is a state of mind which 
does not last long. 

Far more frequently, the mental condition of the menopause is 
one marked by depression. The sane woman at the change of life 
is one who, as a rule, suffers depression rather than mental exalta- 
tion. If the perturbation of the time drifts into a positive mental 
alienation, it is likely to take the form of melancholia and hypochon- 
dria, and passive forms of hysteria. Not that more active forms of 
insanity are excluded. At this period may appear strong irrespon- 
sible impulses, active moral perversions, delirium and acute mania. 
Of these, and of all sorts of insanity, it may be said that the prognosis 
is good if there are not too many neurotic defects in the ancestry. 

At the menopause, that which seems to be an insanity or a radical 
change of character, newly acquired, is, upon close study, seen to be 
merely an exfoliation of mental habits formed in the best years of 
life. Thus stripped, the patient returns to her earlier mental condi- 
tion revealing traits which were suppressed through her young 
womanhood. In one woman we may see something of childlike trust- 
fulness and pliability appear; in another, disagreeable childish traits 
appear when the veneer has been peeled off; and she who was tidy is 
slovenly in her house or her person, becomes stubborn about small 
matters and is absolutely frivolous in conversation and in behaviour. 
Addiction to alcohol and other nerve-tickling drugs sometimes be- 
comes pronounced at this time, and the demand for these drugs seems 
to have no other basis than childish ennui and a babyish lack of self- 
control. The patient, no longer busy in life, no longer self-centred, 
can not abide solitude and relies wholly on company. She becomes 
exacting in small matters, and jealous, not of her husband alone, but 
of all upon whom she has claims. It is a curious fact, and fortunate, 
that many such cases, having fallen into this advanced senile state, 
will work out of it again and go through many years of later life sane 
and serene. 

No doubt we pay too much attention to the physical changes ac- 
companying the menopause and too little to the tremendous mental 
change which comes to every woman at that period of life. A man 
grows old by merciful and gentle gradations, and so he slides, half 
willingly, and half unconsciously, into the afternoon of life, with 
regrets so soft that they can scarce provoke a sigh. But for a woman, 
man's twenty years of gentle change are compressed into two ; she is 
rudely compelled to make an abrupt change of mental attitude as 
regards life and love, and the big world and the great future. It is 



742 A TEXT-BOOK OF GYNECOLOGY 

evolution for him; it is revolution for her. She is suddenly brought 
to perceive that her charms, her youth, her sex itself, are passing 
from her. She is invited, with cruel abruptness, to be to her hus- 
band merely an intellectual companion or a sexless helpmeet, when 
she has been of late the object of his embraces and the mother of his 
babes. One third of her adult life is still before her, full of promise 
of placid enjoyment and great usefulness, but to her, remembering 
the glory of conquest and surrender, the future stretches a dreary 
waste of empty years. 

It appears small wonder, therefore, that, with this sudden violence 
done to lust and love and pride and hope, the woman at the climac- 
teric, finding a sharp boundary set to her warm young life, beyond 
which she must walk into a gray and passionless old age, should be 
the victim of a sadness which may drift into a melancholy and so into 
a madness. The explanation of the psychoses and the neuroses of 
the menopause is not to be sought in absolute senility, nor in the 
accumulation of menstrual poisons, nor in the lack of ovarian juices, 
so much as in the suddenly changed mental atmosphere of her who 
stands reluctantly between youth and age, bereft of all that she most 
valued in herself. 

Treatment. — The menopause, itself, needs no treatment. But 
since it is a season of nervous depression, and a time when the vital 
powers are failing, latent diseases and defects, hitherto well borne or 
suppressed, assert themselves. 

The gouty diathesis or the rheumatic taint may demand treatment 
by elimination, regulated diet, and prescribed muscle waste. A syphi- 
lis may need a course of treatment after it has been forgotten for 
years. 

Perineal and cervical lacerations, hemorrhoids and varices, may 
cry for attention, not merely because the menopause is at hand, but 
because the woman is no longer young, and repair is slow, resisting 
power is lessened, and inhibition by the higher centres over the irri- 
tated lower centres is withdrawn in some degree. 

Climacteric fat may become a burden so grievous that the inges- 
tion of hydrocarbons must be restricted, drink must be limited, and 
vapour baths and physical exercise must do the rest. 

Dyspepsia, diarrhoea and constipation may be so extreme as to be 
interpreted as manifestations of profound disturbance of the sym- 
pathetic supply of the intestines by an irritation proceeding from 
the genitalia. At this time, errors of diet and regimen will tax the 
patience of the physician who would detect and correct them. 

The circulatory disturbances of the menopause are mostly affec- 
tions showing stimulation of the accelerators. Digitalis is much 
abused in these cases. Veratrum viride is more indicated when a 
sound heart is to be dealt with. 

The heart is not involved in the curious flushes and subjective 
flashes of heat. The bromides, used with due regard to their depress- 



THE DISORDERS OF MENSTRUATION 743 

ing effect, will yield very good results in these cases. Many women, 
when they are made to understand the nature of these sensations, do 
not care to have treatment for them. 

Insomnia is a very troublesome symptom of this time of life, and 
will demand careful treatment. The patient may take a certain 
amount of hypnotics, but always with the knowledge that they are 
great evils, introduced only for emergencies, and that the main re- 
medial agents must be open-air life, moderate fatigue at bedtime, a 
mind at rest and plain food. The attendant who is justified in the 
occasional use of hypnotic medicines will do well to keep his own 
counsel, and never permit the name of the drug to cross his lips, 
attributing each sound sleep to anything other than the drug he has 
used. If his wakeful patient becomes his confidante he will find him- 
self unable to baffle her when she sets herself to use drugs for the 
induction of sleep at her own pleasure. 

Tachycardia, mild or severe, occurring at the menopause, will usu- 
ally end in recovery when the ovaries have had time to lose their 
nerve elements and have ceased to tease the sympathetic system. The 
cases in which there is a dilatation of the heart do not tend to recov- 
ery, though they usually improve after the patient has ceased to 
menstruate for some years. Plainly, the source of irritation is not 
always in the contracting ovaries; tachycardia has, in rare cases, come 
to an end after the removal of cicatricial tissue at a laceration of the 
cervix. 

In some few cases with great nervous fretting and poor nutrition, 
a period of rest and seclusion away from home may avert absolute 
insanity. This treatment, with high feeding, is indicated especially 
for women who have long been overworked. The beneficial effects 
upon the thoughtless or deliberately cruel home people is sometimes 
the chief justification for sanitarium treatment. There are many 
patients, on the other hand, who are in danger of grave psychoses 
because they have nothing to do, and it may be possible for the physi- 
cian to suggest some avenue through which the patient may find her 
way to useful work, renewed zest in life, and some promise of a mind 
at peace. Certain it is, that mere drug therapy can avail little for 
those who are overworked or for those who have no occupation. 



CHAPTEE XLVII 

THE FEMALE URINARY APPARATUS 

Physical examination — Catheterization of the ureters : Pawlik-Kelly method ; use 
of the ureterocystoscope — Harris urine segregator — Anomalies of the kidneys in 
number, location, form — Movable kidney, etiology, pathologic anatomy, symp- 
tomatology, treatment — Anomalies of the ureters — Stricture of the ureters — 
Nephrocystosis : Nephrydrosis ; nephropyosis ; pathologic changes, symptoma- 
tology and diagnosis, treatment. 

Physical Examination. — In all examinations of the kidney, the 
abdomen should be thoroughly exposed by the removal of all cloth- 
ing. The examination may be made with the patient lying on the 
back, on the side, or standing. When on the back, the shoulders 
should be slightly raised and the limbs drawn up to relax as much as 
possible the abdominal muscles. With the palmar surface of the 
fingers of one hand, counter pressure is made posteriorly just below 
the twelfth rib, while the other hand presses upward and backward 
beneath the costal arch external to the rectus muscle. The patient 
should now take a deep breath, and during the expiration, the anterior 
hand should follow the receding abdominal wall. The kidney, if it 
descends far enough, may be grasped between the hands and its surface 
easily palpated. 

In the side position, the patient lies on the side opposite the one 
to be examined. The body should be curved slightly forward and the 
limbs drawn up. In this position the kidney, if movable, drops to- 
ward the middle line and may be more easily felt. 

The standing position is to be preferred when examining for " pal- 
pable " kidneys, for " movable " kidneys of low degree, or when the- 
superior pole tilts forward. The body should bend gently forward 
with the hands resting on a table or chair. The kidney can often be 
palpated in this position when it can not be felt lying down. The 
kidney is recognised as such by its shape, its range of motion, its rela- 
tion to the colon, and its return to the normal location by manipula- 
tion or position of the body. The shape can not be better expressed 
than by the well-understood expression " kidney-shaped." The range 
of motion of the mass is of considerable diagnostic value. In movable 
kidney, the range of motion is usually through an arc of a circle, the 
vessels forming the pedicle representing the radius, while the origin of 
the vessels corresponds to the fixed point or centre. The majority of 
744 



THE FEMALE URINARY APPARATUS 745 

movable kidneys pass below the transverse colon and behind and to 
the inner side of the longitudinal colon. When the superior pole tilts 
forward, the rounded end may be felt just below the edge of the liver 
and above the transverse colon. It may resemble very much an en- 
larged, distended gall bladder, and diagnosis is often difficult. The 
diagnostic points, aside from the history, are these : The kidney may 
usually be felt with the hand behind as well as in front, which is not 
often the case with the gall bladder. The kidney may be returned to 
its normal location by manipulation or when the patient lies down, 
the tumour disappearing; while though the gall bladder, if it has a 
long mesocyston, may be crowded back under the liver thus partially 
disappearing, it tends to return forward to its normal position so soon 
as the pressure is removed. A so-called " Schniirlobe " of the liver 
may closely simulate a movable kidne} r , but its connection with the 
liver can usually be made out. 

Very small tumours may rarely be detected in palpable kidneys by 
the slight irregularity or protuberance produced on the surface of the 
organ. Tumours of the kidney that are of sufficient size to form dis- 
tinct enlargements, can usually be outlined without much difficulty. 
One of the most important diagnostic points in connection with these 
tumours is the relation that they bear to the longitudinal colons. As 
the kidney lies in the retrocolonic space, enlargements of it from 
whatsoever cause displace the colon forward, forward and inward, or 
inward. Deviations from this rule are the exception, and occur usu- 
ally in enlargements of movable kidneys. The relation of the colon 
to the tumour can always be easily determined by having the bowel 
thoroughly emptied; then the tumour should be mapped out on the sur- 
face of the abdomen and the colon gently distended with air by means of 
an ordinary rubber hand bulb. Having decided that a tumour is con- 
nected with the kidney, it is next desirable to know if it is solid or cystic. 
This can often be determined by the sense of touch and the presence 
or absence of fluctuation. At times, however, fluctuation is so doubt- 
ful that one is unable to decide. In such a case, the aspirating needle 
may be used with the usual aseptic precautions. It should always 
be introduced posteriorly so that the peritoneal cavity may not be 
entered. Should fluid be withdrawn, its character will determine the 
nature of the enlargement, whether simple cyst, nephrydrosis, nephro- 
pyosis, echinococcus, etc. 

The surface of the tumour should be palpated to ascertain if it is 
smooth and uniform, or irregular and nodular. Of the former class, 
are the simple cystomata and usually the large rapidly growing 
" mixed tumours " of childhood. Of the latter, are congenital multi- 
ple cystic kidney, infected kidneys with multiple intranephric and 
perinephric abscesses, and some malignant growths. 

Tumours of the kidney are usually movable, particularly during 
their early stage. Later, they may become fixed by adhesions to sur- 
rounding parts. A careful examination of the urine is of great im- 



746 



A TEXT-BOOK OF GYNECOLOGY 



Fig. 299.— Urethral 
dilator.— Harris. 




8 



portance in the diagnosis of renal diseases. In order to determine 
accurately the point of origin of pathologic products in the urine, it 
may, at times, be necessary to collect the urines directly from each 
kidney separately. This may be done by catheterizing 
the ureters or by the use of the Harris urine segre- 
gator. 

Catheterization of the Ureters. — There are two 
methods at present in use of catheterizing the ureters. 
These are the Pawlik-Kelly method and the use of 
the ureterocystoscope. 

In the Pawlik-Kelly method the instruments neces- 
sary, as given by Kelly, are the following: A conical 
urethral dilator (Fig. 299); several specula with ob- 
turators (Fig. 300), Nos. 8, 8J, 9, 9J, 10; a light; a 
head mirror; an evacuator; long recurved mouse- 
toothed forceps (Fig. 301); a 
ureteral searcher (Fig. 302); flex- 
ible ureteral and renal catheters; 
a metal ureteral catheter; hard- 
rubber bougies, and a series of 
dilating catheters. The bladder 
should be completely emptied of 
its urine and the patient placed 
in the knee-chest position on a 
table. The urethral orifice should 
be cleansed with a boric-acid solu- 
tion, the urethra dilated, if necessary, with the 
conical dilator, and a properly sterilized speculum, 
No. 8, 9, or 10, introduced into the bladder. Upon 
withdrawing the obturator the bladder immedi- 
ately distends with air. The vagina, likewise, usu- 
ally distends with air, but when it fails in this, as 
is likely in the vir- 
gin, it may be neces- 
sary to introduce 
into the vagina a 
very small cylindri- 
cal speculum or one 

„ r , \ ^^ Fig. 300.— Speculum with 

of the urethral spec- >f obturator.-HABBis. 

ula, when the air 

will readily enter and the speculum may be withdrawn. 

The light is now reflected from the head mirror into the 

bladder, illuminating it so that its interior may be readily 

examined. The speculum is withdrawn until the internal 

end of the urethra begins to fold over it. Now, by pushing it straight 

in for a distance of about 1 centimetre, and then deflecting it laterally 

about 25° or 30°, the ureteral orifice usually comes into view. This has 




THE FEMALE URINARY APPARATUS 



T47 



Fig. 301. 
Mouse- 
toothed 
forceps. 
— Harris 
(page 746) 



the appearance of a small narrow slit, a slight elevation or papilla, 
or sometimes of a small fold in the mucous membrane. If the ure- 
teral orifice does not readily present itself after the end of 
the speculum has been directed to the location where it 
presumably ought to be, it may be sought for with 
the searcher. When found, it should be carefully 
wiped off with a piece of cotton wet in boric-acid 
solution, and the catheter gently introduced. If de- 
sired, the speculum may be withdrawn, the patient 
turned on the back and the catheter allowed to re- 
main until sufficient urine has been collected for 
analysis. 

The chief advantages of this method are that the 
instruments necessary are simple and inexpensive, and 
that it permits cleansing of the ureteral orifice by 
direct application before introducing the catheter. 
The method, however, is not so simple as it appears. 
Much practice and dexterity are necessary, and nu- 
merous failures will be recorded by the occasional 
user. Besides, an anaesthetic is often necessary in 
order to secure perfect ballooning of the bladder, 
when two trained assistants or a special apparatus 
will be required to hold the patient in position. 

Catheterization by Means of the Cysioscope. — By 
this method the catheter is introduced into the ureter 
under the guidance of the eye by means of one of the 
ureterocystoscopes, such as Casper's, Nitze's, Albar- 
ran's, Brenner's, etc. (Fig. 303). The bladder is thor- 
oughly cleansed by irrigation, and about 100 to 150 
cubic centimetres of clear boric-acid solution allowed 
to remain in the bladder. The cystoscope, prop- 
erly sterilized, is then introduced, and the interior 
of the bladder illuminated by the electric light. The 
I ureteral orifice is sought for by inspection, and, 
^ when found, the catheter, passed along the small 

canal in the instrument, is directed toward, and 
made to enter, the ureter by the sense of sight. 

The Harris Urine Segregator (Fig. 304) 
By this instrument the urines are collected 
separately from each kidney without 
the ureters being entered (Fig. 305). The 
patient is placed on the back in an easy 
lithotomy position with the hips on the 
same level as the shoulders. The blad- 
der, after being thoroughly cleansed 
by irrigation, is distended with about 150 cubic centimetres of sterile 
water. The double catheter, sterilized by boiling, is introduced into 




Fig. 302.— A ureteral 
searcher. — Harris 
(page 746). 



748 



A TEXT-BOOK OF GYNECOLOGY 



the bladder and the lever into the vagina. After these two pieces are 
locked by means of the small pin in the forked piece, the catheters are 
opened and fastened by means of the small spiral spring. The rubber 
tube connecting the curved tips of the catheters is now removed and 




Fig. 303. — "One of the ureterocystoscopes." — Harris (page 747). 

the water within the bladder allowed to escape. The vials are attached 
and, by means of the most gentle action of the bulb, the urine will be 
found to collect in the vials, right and left respectively, as fast as it 
escapes from the ureters. Each of these methods has its advantages. 
By means of the cystoscope, the interior of the bladder may be accu- 
rately inspected, and local conditions, such as inflammatory changes, 
ulcers, incrustations, new growths, etc., recognised. By catheterization 
of the ureters the urine may be collected and the pelvis of the kidney 
drained and then treated by irrigation. The use of ureteral bougies 
will often enable one to recognise the ureter more readily in certain 

operations in the pel- 
vis, or to locate the 
divided ends of an in- 
jured ureter. One 
may be able to detect 
the presence and loca- 
tion of a stricture or 
obstruction of the 
ureter, possibly to 
dislodge a calculus 
from the ureter, and 
rarely to detect a cal- 
culus in the pelvis of 
the kidney. The great 
disadvantage of the 
ureteral catheter is the danger of infecting a healthy ureter and kid- 
ney. This danger is so real that, in the presence of a septic bladder, 
or in tuberculosis of the bladder or of one kidney, a healthy ureter 
should never be catheterized except under the most urgent necessity. 

The great advantage of the urine segregator is that it may be 
used without danger of infecting a healthy kidney, even if the bladder 
is septic, as the instrument does not enter the ureteral openings. 




Fig. 304. — The Harris urine segregator. — Harris (page 747). 



THE FEMALE URINARY APPARATUS 



749 



Anomalies of the kidneys may be considered under three heads: 
(a) Anomalies of number; (b) Anomalies of location; (c) Anomalies 
of form. 

Anomalies of Number. — Absence of both kidneys has been observed, 
but the condition is incompatible with prolonged post-natal existence. 




Fig. 305. — u By this instrument the urines are collected separately from each kidney without 
the ureters being entered." — Harris (page 747). 



Absence- of one kidney, provided the other is normal, is perfectly 
compatible with health and existence to old age. This condition is 
found in one individual in about 3,000, and is thus of considerable 
surgical importance. The remaining kidney is called a " single " or 
" solitary " kidney. 

Ballowitz (Archiv fur patlwlogische Anatomie, Bd. cxli) has collected 
213 cases of " single " kidney. The left kidney was absent 70 times, 
and the right, 42 times, in males; the left, 31 times, and the right, 
34 times, in females. Eemainder unstated. While in men the 
absence of the left kidney distinctly predominates, in women, the two 
sides are about equally represented. 

With absence of a kidney is frequently found some developmental 
defect in the generative organs of the same side, such as absence of 



750 A TEXT-BOOK OF GYNECOLOGY 

the ovary and tube, and uterus unicornis in women, or absence of 
the seminal vesicle, vas deferens, or testicle, or unilateral prostate, in 
men. In 71 women, such defect was found 41 times, while in 113 
men, it appeared only 28 times. A " single " kidney is almost always 
larger than normal. In 116 cases, the kidney was distinctly hyper- 
trophied, while in only 5 cases was it found smaller than normal. 
Nephrydrosis, chronic inflammatory, or other pathologic changes, were 
found in nearly 12 per cent of Ballowitz's 213 cases. " Single " kid- 
ney has been unwittingly removed a number of times for disease, with 
the inevitable death of the patient as a result. In all cases, there- 
fore, in which nephrectomy is contemplated, the possibility of " sin- 
gle " kidney must first be excluded. In " single " kidney, almost 
always but one ureter is found opening into the bladder, and this is of 
great diagnostic importance, but in 4 cases, 2 ureters were found 
opening into the bladder at their normal locations, the one leading 
to the kidney, the other forming only a shorter or longer blind tube. 
" Single " kidney usually occupies the normal location on one or 
the other side, but may be displaced as described under anomalies of 
location. 

A few cases have been described in which three kidneys were said 
to be present. Most of them were probably cases in which one kidney 
had become subdivided into two portions by a deep furrow extending 
entirely through it, the two portions becoming somewhat displaced 
from each other, and the ureter from each soon uniting to form a 
common ureter. Cheyne (Lancet, 1899, vol. i, p. 215), however, de- 
scribes a case of a woman on whom he operated for a movable tumour 
situated to the right of the middle line. Upon opening the abdomen the 
tumour was found to be a movable third kidney with its own ureter 
and blood supply. It lay near the pelvic brim from 3 to 4 inches from 
the normal right kidney, which was present. A left kidney, some- 
what smaller than normal, was present in the usual location. 

Anomalies of Location. — The kidney may occupy any position from 
the normal above, to within the pelvis below. Both kidneys may oc- 
cupy the same side of the body, lying one above the other. The ureter 
of the misplaced kidney usually crosses over to its proper side where 
it enters the bladder at the normal place. The most common mis- 
placement is at, or near, the brim of the pelvis, over the sacro-iliac 
joint, or just within the pelvis. Of 76 collected cases of pelvic mis- 
placement, the right kidney was misplaced 12 times, and the left 64 
times. The ureter is shorter than normal, according to the degree 
of misplacement, but enters the bladder at the usual point. The blood 
supply is derived from the aorta near its point of bifurcation, or from 
one or the other iliac arteries. The kidney is usually fixed, and some- 
what flattened from before backward. When in the pelvis, the kidney 
may be the cause of dystocia by preventing the engagement of the 
head. In such a case, Cragin did a vaginal nephrectomy under the 
supposition that it was a tumour causing the dystocia. Goulliund 



THE FEMALE URINARY APPARATUS 751 

operated on a pelvic kidney under the mistaken diagnosis of in- 
terstitial salpingitis. Misplaced kidneys may be the seat of pathologic 
changes. 

Dartigues operated on what he supposed to be a cyst of the mesen- 
tery, but found a case of nephroptosis in a kidney misplaced in the 
mesentery of the small intestine. Such cases have only been diagnosti- 
cated at or after the operation, but in all cases of unusual tumours in 
the pelvis or about the pelvic brim, the possibility of a misplaced kid- 
ney should be considered. In misplaced kidney, the adrenal does not 
usually accompany the kidne}- but remains in its normal location. 

Anomalies of Form. — The kidney may retain its fcetal lobulated 
form, deep fissures, often extending to the pelvis, separating the lobules. 

The most important anomaly of form is the " fused " kidney. In 
this condition the two organs are united, the degree of union, or 
fusion, varying from the simple horseshoe kidney to almost com- 
plete fusion into one organ. In the variety called " horseshoe " kidney, 
the two organs lie one on either side of the vertebra?, their lower poles 
being connected by a band of tissue called the isthmus, which extends 
across the vertebra? in front of the aorta and vena cava. The isthmus 
may be composed simply of a band of connective tissue, or it may 
contain kidney tissue. It may be quite long, or the lower poles may 
be fused directly together, in which latter case a connective-tissue 
septum usually separates the kidney elements belonging to one organ 
from those belonging to the other. The pelves are usually directed 
more anteriorly than normally, and the ureters pass in front of the 
isthmus. Barely, the isthmus extends between the upper poles instead 
of the lower. 

The fused organs may both lie on the same side of the body, in 
which case the lower of the two is the misplaced organ. The lower 
pole of one fuses with the upper pole of the other, with the pelves 
looking in opposite directions or in the same direction. Almost all 
degrees of fusion may take place, but the pelves usually remain com- 
pletely separate and distinct, each having its own pyramids and tubules 
supplying it, and each having its own ureter. One half of a fused organ 
may be the seat of pathologic changes, while the other half remains 
normal, a fact of considerable surgical importance. Abnormities in 
the blood supply are almost always present. Fusion does not appear to 
predispose to disease. According to McMurrick (International Journal 
of Surgery, 1898, vol. xi. p. 335), 10 per cent of the fused organs were 
on the right side and 60 per cent on the left: T8 per cent occurred in 
men and 22 per cent in women. 

Under the anomalies of form, may be mentioned the " suppressed," 
or congenitally small kidney. In this case the kidney has been arrested 
in its growth so that often but a remnant of the organ is found. A 
" suppressed " kidney may secrete urine of normal composition, but 
in quantity insufficient to maintain life should the opposite organ re- 
quire removal. 



752 A TEXT-BOOK OF GYNECOLOGY 

Movable Kidney. — The kidneys, although classed as fixed organs, 
move up and down with respiration, the normal range of motion vary- 
ing from 2 to 5 centimetres in a longitudinal direction. As a rule, 
the normal kidney can not be palpated through the intact body walls 
in men, but in women the right can be distinctly felt in a majority of 
the cases, and the left in a much smaller proportion. The extent to 
which the kidney may be felt, varies from the lower third to the major 
portion. It is best sought with the person standing, the body bent 
slightly forward so as to thoroughly relax the anterior abdominal 
muscles. The volar surfaces of the fingers of one hand should be 
pressed firmly against the loin beneath the twelfth rib, while those of 
the opposite hand are crowded upward and backward beneath the costal 
arch in front. While the person takes a deep breath, the kidney, if 
palpable, may be grasped between the two hands. A kidney that can 
thus be felt is called a " palpable kidney." A kidney may be " pal- 
pable " without being movable. By the term " movable kidney," is 
meant one which is not only palpable, but which likewise possesses a 
degree or range of motion in excess of the normal. There are all degrees 
of mobility in u movable kidney." It may move up and down but 
slightly in excess of the normal, or it may descend as low as the true 
pelvis. It may move forward beneath the costal arch as far as the 
anterior abdominal wall, or it may be moved inward to considerably 
beyond the middle line. Most English writers divide this subject 
into " movable " and " floating " kidney, the former being considered 
an acquired, the latter a congenital condition. The " floating " kidney 
is described as possessed of a mesonephron of congenital origin which 
permits of a wide range of motion. As }^et no anatomic facts have been 
presented which demonstrate the congenital origin of a mesonephron, 
consequently the condition must be considered one of degree only, and 
the term "movable" kidney will here be used for all degrees of mobility. 

Movable kidney is a very common condition, but statistics based 
upon dead-house reports are very misleading. This unreliability of 
dead-house statistics is due mainly to two reasons: First, the condition 
rarely plays any direct part in the cause of death, and consequently is 
frequently overlooked; and, secondly, when the patient assumes the re- 
cumbent position, the kidney usually returns to its normal location, 
and the post-mortem solidification of the perirenal fat limits its degree 
of mobility. We therefore turn to clinical experience to determine the 
frequency of this condition. Ivuster examined in order 1,733 patients 
as they applied to him in private practice, and found 44 cases of mov- 
able kidney. There were 828 men with 4 cases, or 0.48 per cent, and 
905 women with 40 cases, or 4.41 per cent. This is a good illustration 
of the general average in a surgical practice. In an exclusively gyneco- 
logical practice, the percentage is much higher, as not far from 20 per 
cent of such cases will be found to have " movable " kidney (Edebohls). 

In considering the etiology of movable kidney, two facts stand out 
so prominently that all etiological factors must be consistent therewith. 



THE FEMALE URINARY APPARATUS 753 

These are: First, the proportion of women affected is greatly in excess 
of men; secondly, the right kidney is affected much more frequently 
than the left. In 667 cases collected by Kuttner {Berliner hlinische 
^Yoc^^enscllrift, 1890, Xos. 15-17) 584 subjects were women, and 83 men. 
The explanation of this marked predominance of women over men is 
found in the bod} r form. The upper or cephalic portion of the abdom- 
inal cavity is relatively of much smaller capacity in women than in 
men. The cavity is not only contracted laterally, but from before back- 
ward as well. The effect of this is to displace and distort the organs 
occupying this zone of the abdomen. The stomach lies in a more longi- 
tudinal direction and the pylorus is depressed. The liver is compressed 
from before backward, thus depressing its anterior and posterior bor- 
ders. The depression of the posterior border crowds the right kidney 
lower and tends to displace or tilt the superior pole in an anterior direc- 
tion. The increased breadth of the female pelvis gives to the psoas 
muscles a more oblique direction than in the male. This condition 
produces an obliquity in the sagittal axis of the kidney so that the 
superior pole lies nearer the middle line than the inferior. The rela- 
tion between the body form and the location of the kidney is so con- 
stant, that by dividing the length of the body from the suprasternal 
notch to the upper border of the symphysis pubis by the least circum- 
ference of the body, an " index " will be found from which it may 
confidently be predicted in a given case whether the kidney will be 
found palpable or not. The formula of this index as expressed by Becker 
and Lennhoff (Deutsche medicinische YYocliensclirift, 1898, Bd. xxiv, p. 

nn . . „ „ distance iugulo-svmphvsis . _ „ 

508) is as follows: —^ — J . * . J \ " X 100 = index. The 

least abdominal circumference 

greater the index, the smaller the upper zone of the abdomen, and 
vice versa. Therefore the greater the index, the lower the kidney will 
be found. With an index above 77, the kidney is almost always " pal- 
pable/ 7 while with an index below 75, it is the exception to find a " pal- 
pable " kidney. The body form must, therefore, be considered the 
predisposing factor in the cause of " movable " kidney, and explains the 
predominance of movable kidney in women over men. 

Etiology. — The chief determining cause is mechanical insult to the 
kidney. Mechanical influences may be divided into internal and exter- 
nal, the former being the more common and important. By internal 
mechanical influences are meant all sudden or severe muscular strains, 
such as heavy lifting, wrenching of the body by slipping or falling, 
straining at stool, coughing, twisting and turning of the body, in fact 
any muscular action that produces adduction of the lower movable ribs 
and thus a constriction of the upper zone of the abdominal cavity. In 
body forms with high indices, it will be found that the plane corre- 
sponding to the least abdominal circumferences cuts the distal portion 
of the floating ribs in women and passes above the centre of the kidney, 
particularly the right. The effect, therefore, of adduction of the lower 
ribs by the internal mechanical influences above mentioned, is to bring 
49 



754 A TEXT-BOOK OF GYNECOLOGY 

pressure on the upper portion of the kidney and thus depress it. In 
men, the before-described plane usually passes below the centre of the 
kidney, so that constriction at this level tends to elevate or compress the 
kidney. 

The truth of the above statements is well exemplified by the statis- 
tics of Kuster (Archiv fur Minische Chirurgie). He found that of 295 
cases of traumatic subcutaneous rupture of the kidney, 92 per cent 
were in men and only 8 per cent in women, while of 84 cases of " mov- 
able " kidney the percentages were almost reversed — namely, 94 per 
cent in women and only 6 per cent in men. 

By external mechanical influences are meant injuries, such as falls, 
sudden jolts of the body, or blows about the region of the kidney. That 
an injury may directly produce a movable kidney, is certain. Harris 
has seen a movable kidney in a man, produced by his being thrown 
from a runaway carriage, and a case in a woman, produced by a fall on 
the buttocks. Cases, however, that are directly and solely attributable 
to a single injury are not common. Usually, the injury but directs atten- 
tion, or aggravates somewhat, a kidney already more or less movable. 

The principal reason why the right kidney is so much more fre- 
quently movable than the left is, unquestionably, the presence on the 
right side of the liver. This organ forms a firm, resisting body which 
transmits all force from above directly to the kidney, and prevents it 
from moving in any direction except downward and forward. The left 
kidney is not only somewhat more firmly fixed in its location, but has 
above it only the small spleen and the soft yielding stomach. 

What has brought about the body form of the female, which is so 
favourable to the occurrence of movable kidney? The broader hips, of 
course, are a sex peculiarity. The narrow contracted waist, however, 
is an acquired condition produced by artificial constriction which has 
been operative for innumerable generations. This constriction is due, 
not alone to the corset, but to the tight skirt bands as well, and the 
latter are often more harmful than the former, as is shown by the fact 
that movable kidney is not uncommon in labouring women who have 
never worn corsets but who constantly constrict their waists with tight 
skirt bands. According to Thomson (Edinburgh Medical Journal, De- 
cember, 1900), however, Trekaki, of Alexandria, finds that 42 per cent 
of Arab women, who wear no corset, girdle, or constriction of any kind, 
have a freely movable kidney. 

There are other conditions that are considered by some authors as 
instrumental in the production of movable kidney. Foremost among 
these may be mentioned pregnancy. That the influence of pregnancy 
has been greatly overestimated is apparent when we learn that from 
30 to 50 per cent of the cases occur in the unmarried, or in those who 
have never borne children. In 188 cases seen and collected by Harris, 
89 were married, 83 were single, and in 6 the condition was not stated. 
Of the married, 4 are stated never to have borne children. Comby 
(British Medical Journal, 1898, vol. ii) mentions 18 cases in children. 



THE FEMALE URIXARY APPARATUS 755 

Two were aged, respectively, one and three months, 6 were between one 
and ten years, and 10 were over ten years of age. The same argument is 
applicable against the statement that laceration of the perineum, with 
prolapse and displacement of the uterus, is a material factor in the 
causation of movable kidney. 

The relaxation of the anterior abdominal wall and diminished intra- 
abdominal tension following the removal of large abdominal tumours 
and fluid accumulations, are supposed to favour the occurrence of 
movable kidney, but in large scrotal hernias in men and in umbilical 
herniaa in women, where the intra-abdominal pressure is often very 
much reduced, movable kidney is not common. Absorption of the 
perirenal fat, as occurs in wasting diseases, has been emphasized par- 
ticularly by Landau as an etiological factor. As it is inconsistent with 
the two fundamental facts stated above, its influence must be consid- 
ered slight. The course of the ureters through the pelvis is too much 
of a curve and too much " slack " is present, as shown by the possi- 
bility of uretero-ureteral anastomosis, for the kiclne}^ to be materially 
influenced by displacements of the uterus and tubal disease drawing on 
the ureters. 

The causes of movable kidney, then, may be summarized thus : The 
principal predisposing cause is the body form. Principal determining 
cause: repeated internal and ex- 
ternal mechanical influences as 
defined above. Of the minor in- 
fluences may be mentioned gen- 
eral relaxation of the abdomi- 
nal walls and kidney attach- 
ments following distention, wast- 
ing diseases, or enervating condi- 
tions. 

The pathologic anatomy of 
movable kidney varies some- 
what according to the degree of 
mobility. Three degrees of mo- 
bility may be described: 1. That 
in which the major portion of 
the kidney is palpable; 2. That 
in which the kidney descends so 
low that the hands may be 

brought together above it (Fig. FlG 306 _ .. The kidney descends so low that 
306); 3. That in which the range the hands may be brought together above 

of motion is so great that the kid- it."— Harris. 

ney may descend to the brim of 

the pelvis, move forward to the anterior abdominal wall, or be moved 

inward beyond the middle line (Fig. 307). In the first and second 

degrees, the kidney moves up and down in the connective-tissue 

space formed anteriorly by the prerenal, and posteriorly by the retro- 




756 



A TEXT-BOOK OF GYNECOLOGY 



I 



..y 



Fig. 307. — " The kidney may descend to the 
brim of the pelvis." — Harkis (page 755). 



renal, fascia. The perirenal fat which varies much in quantity moves 
mostly with the kidney. As the renal fascia passes between the adrenal 
and the kidney, the former remains fixed and does not move with 

the latter. In the third degree, 
the perirenal fat is often much 
less in amount and may almost 
entirely disappear. As the kid- 
ney moves anteriorly, it carries 
with it the prerenal fascia and 
the peritoneum, so that these 
structures gradually surround the 
kidney more and more, forming 
with the vessels and ureter at the 
hilum a pedicle or, as it is some- 
times called, a mesonephron. The 
peritoneum is not firmly attached 
to the kidney as in normal intra- 
peritoneal organs, but loosely 
fixed thereto, being separated 
from it by the prerenal fascia and 
subperitoneal tissue. The renal 
vessels are often considerably 
lengthened. Legueu describes 
vessels that were 11 and 13 centi- 
metres long. The kidney moves through an arc of a circle of which 
the vessels form the radius and their point of origin the centre. 
The range of motion is therefore limited by the length of the vessels. 

The large majority of mov- 
able kidneys belong to the first 
and second degrees. Those in 
which a so-called mesonephron 
is present are quite rare. At 
times the kidney, instead of 
moving up and down in a longi- 
tudinal direction, has its supe- 
rior pole tilted forward, the or- 
gan moving in an anteroposte- 
rior direction, and approaching 
the surface just below the edge 
of the liver between this and 
the transverse colon (Fig. 308). 
Again, the kidney may turn 
about an antero-posterior axis 
so that the hilum looks upward, 
and the superior pole may even 
occupy a lower level than the FlG . 308 .-" At times the kidney ... has its 

inferior. More Or less of the superior pole tilted forward."— Harris. 




THE FEMALE URINARY APPARATUS 



757 



upper portion of the ureter usually moves with the kidney, and there is 
often a marked tendency for the ureter to become sharply flexed or 
kinked at the junction of the movable with the fixed portion. This 
kinking of the ureter may interrupt temporarily the flow of urine pro- 
ducing distention of the pelvis and leading, eventually, to the for- 
mation of an intermittent nephrydrosis (Fig. 309). The renal vessels 
may also be sharply flexed so as to interfere with the blood supply 
to the kidney. A movable kidney may acquire new attachments to 
neighbouring organs, as, for instance, to the duodenum, the under 
surface of the liver, the colon, or 
the small intestine. Such attach- 
ments may limit its mobility or 
prevent its being returned to its 
normal location. Movable kidney 
is frequently associated with de- 
scent of other abdominal organs 
such as the stomach, liver, colon, 
or small intestine. By some au- 
thors, it is considered simply a 
part of a general visceral ptosis 
which is described under the 
name of Glenard's disease. Such, 
however, is not the case, as mov- 
able kidney is often found unac- 
companied by marked displace- 
ment of any other abdominal 
organ. Dilatation of the stom- 
ach has been so frequently found 
in connection with movable kid- 
ney, that a dependent relation is 
claimed, based upon the fact that 
the kidney (right) in its move- 
ments may compress, drag upon, or so kink the duodenum, as to 
interfere with the proper emptying of the stomach, or through nervous 
action disturb stomachic digestion. Frank (British Medical Journal, 
1895, vol. ii, p. 895) mentions a case of movable kidney so attached to 
the duodenum that the intestine would be kinked whenever the kidney 
moved out of place. The characteristic changes of dilatation and 
chronic catarrh are often found in the stomach. In left-sided movable 
kidney, the spleen may also be abnormally movable, but it usually 
retains its proper location. 

Symptomatology. — In a systematic examination of patients, one fre- 
quently finds movable kidneys that have given rise to no symptoms 
whatever, and whose presence was unknown or unsuspected until dis- 
covered incidentally during the examination. On the other hand one 
sees patients whose lives are made miserable by a train of symptoms 
produced by a movable kidney. Between these extremes all degrees 




Fig. 309. — " This kinking of the ureter may 
interrupt temporarily the flow of urine, 
. . . leading to the formation of an inter- 
mittent nepkrydrosis." — Harris. 



758 A TEXT-BOOK OF GYNECOLOGY 

will be found. The number and severity of the symptoms do not neces- 
sarily depend upon the degree of motion present, as there may be more 
suffering in one case with motion of the first degree than in another 
with motion of the third degree. It is, at times, difficult to state why 
one patient should suffer so much and another so little. In sudden dis- 
placement or acute dislocation of the kidney, the result of an injury, 
there is always pain in the side affected, and the patient often states 
that a feeling as if something had given way in the side was experi- 
enced. The pain may be quite severe, and be attended by nausea or 
vomiting. There may be a frequent desire to urinate and, at times, a 
little blood in the urine. That side will be tender to touch, and, on 
examination, the kidney may be felt in its dislocated position. The 
kidney may be found dislocated forward along the under surface of the 
liver, or downward behind the caecum, or inward toward the middle 
line. It may return spontaneously to its normal location or appear 
somewhat fixed, requiring gentle manipulation to reduce it. After 
reduction, the symptoms quickly subside. After an acute dislocation, 
the kidney may regain its former fixed condition, or it may remain 
permanently more or less movable. The symptoms attributable to mov- 
able kidney may be arranged under four heads: Pain; disturbances of 
the urinary organs; disturbances of the gastro-intestinal tract; dis- 
turbances of the nervous system. The pain is located in the lumbar re- 
gion just below the twelfth rib, or anteriorly extending from the costal 
border down the side toward the inguinal region or the bladder. It 
may be located over the region of the appendix, and Edebohls has par- 
ticularly directed attention to the association of appendicitis with 
movable kidney. The pain may be quite acute, or, more commonly, 
a dull aching or a dragging feeling which is aggravated by standing, 
walking, or lifting. 

Of the urinary symptoms, frequent urination is the most common. 
It is most marked when standing, and usually disappears at night or 
when lying down. The desire to urinate frequently may be periodic. 
Harris had a case of a woman with a movable right kidney who, at 
irregular intervals, would have severe attacks of painful, frequent 
urination, lasting several hours. She was permanently relieved by 
fixing the kidney. 

Gastric symptoms are among the most common with which these 
patients are affected. They are the usual symptoms noted in gastric 
dilatation and chronic catarrhal gastritis, such as pain and distress 
after eating, eructations, nausea, and, at times, vomiting. There is 
tenderness on pressure in the epigastric region, and the abdominal aorta 
pulsates so markedly at times that one may be led to suspect an 
aneurism. Futterer calls attention to a bruit sometimes heard over the 
renal artery, which he considers due to a partial kinking of that vessel. 
Barely, jaundice has been noted, caused probably by the kidney draw- 
ing on the hepatico-duodenal ligament. Constipation is the rule and 
flatulence common. In connection with the nervous system, we And 



THE FEMALE URINARY APPARATUS 759 

dizziness very common, headaches, frontal or occipital, and, at times, 
all the vague nervous disturbances of hysteria and neurasthenia. 
Sometimes, the mental state is one of depression or despondency 
amounting almost to melancholia. Patients with movable kidneys are 
liable to acute attacks, at irregular intervals, which are quite charac- 
teristic. They consist of acute pain in the region of the kidney often 
extending down the ureter to the bladder, with frequent, scanty urina- 
tion, and nausea or vomiting. These attacks may be very severe and 
may simulate renal colic due to calculus. They are called DietFs crises 
and are probably due to a sudden twisting of the pedicle, causing a 
kinking of the renal vessels and ureter and a drawing on the renal 
nerves. They disappear on returning the kidney to its normal position. 

Many of the foregoing symptoms will be found aggravated during 
menstruation, and the kidney at this time is usually somewhat larger 
and more tender to pressure. It is not to be expected that all these 
symptoms will be present in any one case, but the cases may usually 
be grouped according to the prominence of particular symptoms. We 
thus find that in some cases the symptoms are referred principally to 
the urinary organs, in others to the gastro-intestinal tract, and that 
in yet a third group the nervous symptoms are the most prominent. It 
should also be remembered that movable kidney is frequently found 
associated with other conditions, such as lacerations of the pelvic floor, 
uterine displacements, tubal and ovarian diseases, chronic appendicitis, 
gastric disturbances due to other causes, visceral ptosis, anaemia, etc., 
so that, in individual cases, judicious discrimination is often necessary 
in assigning to each condition its proper influence in determining the 
symptoms present. Owing to the relations of the right kidney to the 
duodenum and bile tracts, gastric symptoms are usually more pro- 
nounced when the right kidney is involved than when the left alone 
is movable. The diagnosis of movable kidney must always rest on the 
findings of a physical examination. (See Physical Examination.) 

The treatment of movable kidney is palliative and operative. Pallia- 
tive treatment consists of the use of abdominal supports, pads and 
trusses, massage and symptomatic treatment. In patients with lax, 
dependent abdomens, with or Avithout general visceral ptosis, the use of 
a well-fitting, firm, abdominal supporter is often followed by marked 
relief. In those cases in which the superior pole of the kidney tilts 
forward, and the kidney approaches the anterior wall below the edge 
of the liver, a properly applied pad may materially aid in retaining it in 
position, but, in the majority of cases, in which the kidney has a down- 
ward movement, it is practically impossible to retain it in place by pad 
or truss, and most observers are agreed that the use of mechanical 
appliances is here without material benefit. Massage has been recom- 
mended particularly by Kumpf with the idea that thereby a retraction 
of the peritoneum around the kidney may be brought about, thus fixing 
it again in place. That such result is ever obtained is more than 
doubtful. However, massage may be of benefit in restoring tone to a 



_ 






760 A TEXT-BOOK OF GYNECOLOGY 

relaxed abdominal wall, in overcoming constipation, and in improving 
digestion, thus relieving many of the symptoms accompanying this con- 
dition. 

Symptomatic treatment should deal with the condition of the 
stomach, the constipation, the anaemia, the nervous symptoms, etc. In 
this manner, all associated or incidental conditions may be relieved, 
leaving such as are due directly to the movable kidney. A movable 
kidney can be permanently restored to its normal location by operation 
only. Not all cases, however, require operation. Operation is advis- 
able: 1. When distinct symptoms are present which are unrelieved by 
mechanical or symptomatic treatment; 2. Where secondary changes 
in the kidney are present, due to the mobility (nephrydrosis, nephritis). 
In those cases associated with general enteroptosis, an operation on 
the kidney should be followed by mechanical support of the abdominal 
wall. Those cases which are relieved by pads or trusses should be 
given the option of an operation with release from the annoyances of 
mechanical appliances. The gravity of the operation in uncomplicated 
cases is slight, the mortality being from 1 to 2 per cent — 374 cases with 
4 deaths (Albarran). Belief from symptoms is most marked in those 
cases in which pain, and urinary and gastric disturbances, are most 
prominent. In such, the results are usually very gratifying. In the 
distinctly nervous type, much less can be promised, as such patients 
are frequently confirmed neurasthenics or hysterical, and such states 
are likely to persist. 

However, if it can be shown that the nervous state has its origin 
in the movable kidney, much good may result from the operation. The 
operation is that of nephropexy or fixation of the kidney. (See Opera- 
tion on the Kidney.) 

Anomalies of the Ureters. — The most common anomaly of the 
ureter is duplication. This may occur unilaterally or bilaterally. 
The second ureter may extend from the kidney to the bladder, open- 
ing into this organ usually a little above the normal opening, or the 
supernumerary ureter may join its fellow at any point along its 
course. It may terminate at the bladder in a blind tube which, as 
it becomes distended with urine, may project into the bladder as a 
cystic pouch. This pouch may even obstruct the opening of the nor- 
mal ureter and thus give rise to a nephrydrosis. The ureters may 
open abnormally into the bladder, both ureters opening on the same 
side. A ureter may open near the internal orifice of the urethra or 
even into the urethra or the vestibule alongside of the meatus uri- 
narius. In the latter two cases, permanent incontinence of urine 
will be present, as the urine will escape continuously from the open 
ureter, and a surgical operation, having for its object the implanta- 
tion of the ureter into the bladder, will be necessary to correct the 
condition. 

Stricture of the ureter may result from cicatricial contraction fol- 
lowing internal trauma due to the passage of a stone; to laceration 



THE FEMALE URINARY APPARATUS 761 

from overstretching of the body, and to injury from external vio- 
lence. The contraction leads to dilatation of the ureter (hydro-ureter) 
above the seat of the obstruction and to the development of a nephro- 
cystosis (q. v.). 

The latter condition usually first directs attention to the possi- 
bility of a stricture which may then, at times, be located by means of 
the ureteral bougie. Attempts have been made, and with some suc- 
cess, to dilate ureteral strictures by passing bougies as in urethral 
strictures. Should this not succeed, an operation may be necessary. 
The ureter may be reached through an extended oblique incision, the 
peritoneum being raised up and carried inward. The stricture, if it is 
a narrow one. may be divided longitudinally and stitched transversely 
after the manner of the Heineke-Mikulicz operation on the pylorus 
(Fenger); or the stricture may be resected, the upper end of the 
lower portion of the ureter ligated, a small slit made in the canal just 
below the ligature, and the lower end of the upper portion, which 
has been slit up slightly, invaginated into the lower portion through 
the slit in the side and retained by fine catgut stitches (Van Hook). 

Calculi may lodge in the ureter in their passage from the kidney. 
The points at which lodgment most frequently takes place are at the 
contracted portion just below the pelvis, at the point where the ureter 
curves to dip into the pelvic cavity, and just before it enters the blad- 
der. When a stone lodges, it interferes more or less with the free 
passage of the urine along the canal, and the usual changes take place 
above the seat of the obstruction. The stone may ulcerate through 
the walls of the canal and materially increase in size in the little 
pocket which it forms. Harris has seen such a stone lying at the 
brim of the pelvis and measuring over 3 centimetres in diameter. 
There are no characteristic symptoms of ureteral stone. A history 
of acute pain or " colic,'' incident to the passage of the stone from 
the kidney to its place of lodgment, might be elicited and the fact 
that, following such an attack, no stone had been passed might sug- 
gest the possibility of one remaining lodged in the ureter, particularly 
if symptoms of renal enlargement appeared soon after. Very rarely, 
a stone in the abdominal portion of the ureter has been palpated 
through the abdominal wall. Those lodged in the lower portion of 
the canal have frequently been felt through the vagina. Usually, the 
stone is discovered by passing ureteral bougies either from below or 
above, while endeavouring to discover the cause of obstruction in 
nephrocystosis. A stone lodged in the upper end of the ureter has 
been dislodged or pushed back into the kidney by the ureteral bougie. 
When lodged farther down, its passage into the bladder has been 
facilitated by injecting sterile oil through a ureteral catheter below 
the stone (Kolisher. From the lower, or vaginal, portion of the 
ureter, stones have been removed through an incision from the 
vagina, and when in the bladder wall, by dilating the ureteral open- 
ing through the cystoscope or a suprapubic opening. When situated 



_^— 



762 A TEXT-BOOK OF GYNECOLOGY 

in the abdominal portion, it may be removed throngh the extended 
oblique incision mentioned under Operations on the Kidney. The 
ureter should be incised, the stone removed, and the incision stitched 
with fine catgut. If unable to close the ureter, it may be left open, a 
packing of gauze in either case being placed down to the opening to 
guard against leakage. 

In case of injury to the ureter, such as accidental puncture or 
incision during operations within the pelvis, the unilateral wound 
should be closed at once by fine catgut stitches. If completely divided, 
an immediate anastomosis should be made after the method of Van 
Hook (see Strictures of the Ureter), or if near the bladder, the 
proximal end should be reimplanted in the bladder at the most con- 
venient point. In case neither of these procedures is possible, it may 
be necessary, as a last resort, to implant the ureter into the bowel 
and run the risk of an ascending infection of the kidney, or to bring 
the end to the surface at some point leaving a permanent fistula, or to 
remove the corresponding kidney. Fortunately, owing to the success 
of ureteral anastomosis, these latter alternatives will seldom be ne- 
cessary. 

Nephrocystosis. — If the escape of urine from the kidney is inter- 
rupted, completely or incompletely, for a sufficient length of time, by 
any cause acting upon the excretory channels, dilatation of the pelvis 
and calyces of the kidney results, producing the general condition of 
nephrocystosis (cystonephrosis). This condition may be subdivided 
into nephrydrosis (uronephrosis, hydronephrosis) when the fluid con- 
tained in the dilated pelvis is urine or modified urine; and nephro- 
pyosis (pyonephrosis) when the additional element of infection is 
present with the formation of pus. 

Nephrydrosis may be congenital or acquired. The congenital vari- 
ety may be unilateral or bilateral. When bilateral, the child is not 
viable, and hence is not a subject for surgical relief; when unilateral, 
the condition is perfectly compatible with life. The cause of the 
nephrydrosis is usually some error of development such as double 
ureter, one or both of which may be imperforate or stenosed, or im- 
perforation of a single ureter. The ureter may open at some abnor- 
mal point such as the vestibule, vagina, urethra, uterus or tubes, in 
which case the orifice is apt to be small and contracted and the ureter 
dilated above it. The ureter may enter the pelvis of the kidney so 
obliquely, or in such an abnormal manner, as to lead to a valve forma- 
tion interrupting the free escape of urine from the pelvis into the 
ureter. The ureter may be sharply flexed by a malposition of the 
kidney or compressed from without by an abnormal or anomalous 
renal artery. 

As a result of some of these abnormities the dilatation may be 
present at birth, thus being strictly congenital. In other conditions, 
as for instance valve formation at the uretero-pelvic junction, the 
nephrydrosis may not develop to a perceptible degree until many years 



THE FEMALE URINARY APPARATUS 763 

after birth or in adult life. While in these cases the cause of the 
dilatation is of congenital origin, their late development makes it bet- 
ter to classify them, at least clinically, under the head of acquired 
nephrydrosis. The most common cause of acquired dilatations is 
pressure on the ureter in its course through the small pelvis. This 
may be due to carcinoma of the uterus, particularly of the cervix, to 
intraligamentous fibromyomata or other tumours of the small pelvis, 
or to the pregnant uterus compressing the ureter at the pelvic brim. 
(Olshausen, Sammlung klinische Vortrage, 1892.) 

Displacements or prolapse of the unenlarged uterus seldom pro- 
duce obstruction of the ureter. Epitheliomata or other tumours of 
the bladder, if located near the ureteral orifice, may be the cause of 
obstruction. Internal obstruction of the ureter may be due to the 
lodgment of a calculus; to cicatricial contraction, the result of an 
injury inflicted by the passage of a calculus or the uric-acid infarcts 
of early infancy (Bernard); or to strictures the result of external 
trauma or of tuberculosis of the ureter. 

An interesting and important cause of nephrydrosis is movable 
kidney (Landau). Harris has seen a typical case of intermittent 
nephrydrosis of small size, due to a movable kidney kinking sharply 
the upper end of the ureter, also one due to a " Schnur " lobe of the 
liver displacing the kidney and kinking the ureter. Both were com- 
pletely relieved by operative correction of the position of the kidney. 
Not all cases of intermittent nephrydrosis, however, are due to mov- 
able kidneys, as certain valvular formations about the uretero-pelvic 
orifice and other conditions, not always readily explainable, may per- 
mit the irregular or periodic evacuation of the sac. The fundamental 
factor in all cases of nephrydrosis is an obstruction to the escape of 
urine from the pelvis of the kidney. This obstruction, as has been 
shown, may vary much in its nature and location. 

The pathologic changes begin at the point of obstruction and extend 
centrad. Thus, if the obstruction is located at the lower ureteral 
orifice or in the bladder, the entire ureter will be found dilated ; if the 
obstruction is located along the course of the ureter, only that por- 
tion lying above or centrad of it will take part in the dilatation; 
while if the obstruction is at the uretero-pelvic junction the ureter 
will not be involved. There may be multiple points of obstruction 
with sacciform dilatations between them. In enlarging, the ureter 
becomes thickened and elongated and assumes a curved or serpentine 
course. The upper part is particularly prone to assume an S-shaped 
curve (Albarran) which may become secondarily kinked or com- 
pressed by the enlarging pelvis. The dilatation of the pelvis soon 
extends to the calyces (Fig. 310). The pyramids gradually become 
compressed and smaller, and eventually are almost entirely effaced. 
Occasionally, the calyces, instead of forming a part of the general 
pelvic enlargement, present fingerlike prolongations. The secreting 
portion of the kidney becomes flattened and thinned out, resting as a 



764 



A TEXT-BOOK OF GYNECOLOGY 




cap on the enlarged sac. In acute obstructions, the kidney is at first 
markedly congested, and multiple hemorrhages may take place in the 
parenchyma or even in the mucosa of the pelvis. As the enlargement 
continues, the secreting portion of the kidney becomes thinner and 

thinner, the glomeruli 
are flattened out, the 
canals compressed, and 
their epithelial cells lost. 
Eventually, this portion 
of the kidney may be 
so thinned and spread 
out in the sac wall as 
to be no longer detect- 
able macroscopically, al- 
though at this stage a 
little thickening or ir- 
regularity on the inner 
surface of the sac often 
indicates the location of 
a former pyramid. The 
secreting function of the 
kidney is very rarely en- 
tirely destroyed, even 
when kidney tissue can 
no longer be detected 
macroscopically. Ayner found complete destruction of the kidney tissue 
only 11 times in 473 cases (TraiU de chirurgie clinique et operatoire, 
tome viii). The enlargement may vary in size from a slight dilatation 
of the pelvis to an immense tumour filling the abdominal cavity and 
containing from 15 to 20 litres of fluid. The sac wall is usually much 
thickened, but may be quite thin in places. Attachments by adhesions 
to surrounding organs are common, rendering the complete , removal 
of large sacs at times very difficult or impossible. 

Partial nephrydrosis, a condition wherein but a part of the kidney 
is involved in the process, may result when the anomaly of double 
ureter is present with imperf oration or obstruction of one (Heller), 
or when one of the calyces becomes shut off from the pelvis, as has 
been described by Fenger, Israel, and others, and of which Harris has 
seen one example. The contents of the sac are always normal or 
modified urine. In the intermittent variety, the urine may show no 
changes from the normal, or it may contain blood due to the con- 
gestion induced by the retention as mentioned by Albarran (Annates 
des maladies des organes genito-urinaires, 1898, p. 470). 

In the closed variety, the fluid gradually becomes more and more 
changed from normal urine. The specific gravity grows less, the 
quantity of chlorides, phosphates and urea is diminished, the latter 
often being present only in traces. The fluid becomes more serous in 



Fig. 310. — " The dilatation of the pelvis soon extends to 
the calyces." — Harris (page 763). 



THE FEMALE URINARY APPARATUS 765 

character and contains a small amount of albumin with mucous and 
epithelial cells from the mucosa of the pelvis. Traces of uric acid 
and oxalates may sometimes be found, even when all urea has disap- 
peared. The fluid is usually more or less clear, but may be coloured 
by blood from old hemorrhages. Very rarely, the sac may contain a 
quantity of gas, mostly carbon-dioxide, which may give to the tumour 
a resonant sound on percussion. 

Symptomatology and Diagnosis. — The symptomatology, strictly 
speaking, of the ordinary closed nephrydrosis is practically nil. The 
first point which directs attention to the condition is usually the 
accidental discovery of a tumour in the lateral region of the abdo- 
men. The tumour develops so slowly and insidiously that no symp- 
toms, save perhaps a vague sense of uneasiness or fulness about the 
side, are experienced by the patient. There may be no changes what- 
ever in the quantity or quality of the urine passed, or symptoms of 
any kind referable to the urinary organs. As the tumour enlarges, 
symptoms resulting from pressure upon, and displacement of, neigh- 
bouring organs may develop. If the growth of the tumour is observed 
for a time, it will be found to develop from the upper and lateral re- 
gion of the abdomen in a direction downward and inward. If seen 
sufficiently early, the tumour is usually somewhat oval in outline, 
and occasionally in thin subjects with lax abdominal walls the de- 
marcation between the cystic portion and the kidney tissue may be 
detected by palpation. As it enlarges, it becomes globular in shape 
and the surface more uniform. The relations of the tumour to the longi- 
tudinal colon, ascending or descending, respectively, are of very great 
diagnostitial value. This portion of the colon will be found displaced 
forward, forward and inward, or inward. Very rarely, in a nephry- 
drosis developing in a movable kidney, the longitudinal colon will be 
found to the outer side of the growth. The dull area of the tumour 
should be outlined by percussion while the colon is empty. This por- 
tion of the intestine should then be distended with air and the rela- 
tions to the tumour observed. The so-called " renal ballottenient " 
of Guyon is a valuable diagnostitial sign but not pathognomonic of 
a renal tumour. The fact that the tumour contains fluid, may usu- 
ally be determined by the sense of touch and by the presence of fluc- 
tuation. The use of the aspirating needle, as means of diagnosis, is - 
seldom advisable. "When a tumour is present which, owing to its 
location and relations to surrounding organs, may be referred to the 
region of the kidney, segregation of the urines (see Methods of Ex- 
amination) becomes an important factor in the diagnosis. If, by use 
of the urine segregator or the ureteral catheter, no urine is found to 
come from the side corresponding to the tumour and the urine from the 
opposite side represents the entire output, the tumour may, with almost 
absolute certainty, be referred to the kidney as its point of origin. 

In intermittent nephrydrosis, symptoms are frequently present 
which point directly to the kidney as the source of the trouble. Some 



166 A TEXT-BOOK OF GYNECOLOGY 

of these are such as are commonly present in movable kidney, such 
as an aching or pain in the lumbar region or lateral portion of the 
abdomen, nausea, irregular attacks of frequent urination, etc. Har- 
ris had a typical case in a woman who, at irregular intervals, had 
attacks of frequent and painful urination amounting, at times, almost 
to strangury. These attacks usually lasted two or three hours. Dur- 
ing the intervals, there was no difficulty whatever in urinating and 
the urine was normal. In this case, a very movable kidney kinked the 
ureter at its upper portion, producing a mild degree of intermittent 
nephrydrosis. The tumour in these cases does not become so large 
as in the closed variety, and is often scarcely perceptible. In other 
cases, a tumour of moderate size has been noticed by the patient, 
which, at times, suddenly disappears, its disappearance being accom- 
panied by an unusual flow of urine. This rise and fall of the tumour 
is quite characteristic of an intermittent nephrydrosis. Intermittent 
hematuria has occasionally been noticed in these cases. The intro- 
duction of the ureteral catheter up to the pelvis of the kidney may 
drain away the fluid and cause the collapse or disappearance of the 
tumour. The diagnosis of nephrydrosis is never complete without 
taking into consideration the nature of the condition giving rise to 
the obstruction. This should always be carefully sought. The 
course and prognosis of these cases depend entirely upon the nature 
of the obstructing cause. A simple closed nephrydrosis may exist for 
years with little inconvenience to the patient, provided the opposite 
kidney is normal. When both sides are affected, the end in uraemia 
is seldom long delayed. When due to carcinoma of the bladder or 
uterus, death follows as a result of the primary trouble unless that 
admits of successful surgical removal. Intermittent nephrydrosis due 
to movable kidney, usually admits of relief by permanently restoring 
the kidney to its normal location and position. The greatest danger 
in these cases is that they may become infected, thus converting a 
nephrydrosis into a nephropyosis with all the serious accompaniments 
of a septic kidney. A nephrydrosis sac may be ruptured by trauma 
and the contents scattered throughout the peritoneal cavity. This is 
not necessarily serious, provided the contents are sterile, but when 
septic, a fatal peritonitis usually results. 

Treatment. — As nephrydrosis is a secondary condition, dependent 
upon some obstruction to the escape of the urine, the treatment should 
naturally be directed to the cause of the obstruction. We may divide 
the cases into two classes, namely: 1. Those in which the nature of 
the obstruction is known and remediable; and 2. Those in which the 
nature of the obstruction is unknown or irremediable. 

Under the first class we may mention the removal of a tumour 
of the bladder or a vesical calculus that is obstructing the ureteral 
orifice; removal of a uterine or pelvic tumour pressing on the ureter, 
and dislodgment of a calculus obstructing the ureter by means of the 
ureteral bougie or catheter; dilatation of a ureteral stricture with 



THE FEMALE URINARY APPARATUS 767 

the bougie. The use of the ureteral catheter a demeure is recom- 
mended by Pawlik and Albarran in some cases of open nephrydrosis 
due, probably, to valve formation or compression of the upper end of 
the ureter. The catheter has been retained for several days with per- 
manent relief. Nephropexy may be done for movable kidneys. This 
operation should not only fix the kidney, but should fix it in such a posi- 
tion by rotating it, if necessary, about its sagittal axis, that the ureter 
escapes from the most dependent part. In certain valve formations at 
the uretero-pelvic junction, plastic operations after the method of 
Kuster and Fenger may be tried. Strictures of the ureter may be 
relieved or ureteral stones removed by open operation. All the above 
procedures have for their aim the conservation of the kidney and its 
function, and it will be seen how varied is the treatment of this class 
of cases. 

In the second class of cases, we have to deal with the sac or tumour 
itself, as the cause of the obstruction is unknown or can not be dealt 
with directly. "We have to consider here, First : Aspiration or punc- 
ture; secondly, nephrotomy; thirdly, nephrectomy. 

While it can not be denied that the use of the aspirator has been 
followed occasionally by success, still, the relief afforded is usually 
so temporary, and the danger of infection so great, that it can not be 
recommended as a curative procedure. Occasionally, however, aspira- 
tion may be employed for the temporary relief which it affords where 
the patient is greatly oppressed by the enlargement, and her condi- 
tion contraindicates more radical measures; or in the later stages of 
pregnancy when the emptying of the uterus is expected soon to give 
relief to the pressure on the ureter. The needle should always be 
introduced posteriorly, so as not to traverse the peritoneal cavity or 
endanger the intestine. Nephrotomy should always be performed by 
the lumbar route. It is advisable to make the incision so as to be 
able to explore the ureter and locate, if possible, the source and nature 
of the obstruction. If this can not be done, the sac should be opened 
and drained. This will often be followed by permanent recovery but, 
in the majority of cases, a fistula remains that continues to discharge 
urine. Ordinarily, such a fistula is of considerable annoyance to the 
patient by its constant leakage, but, at times, a tight-fitting tube or 
rubber catheter may be adapted to the fistula and opened at regular 
intervals with little inconvenience. Nephrotomy should always be the 
operation of choice when the state of the opposite kidney is in doubt. 
However, when the opposite kidney is known to be healthy, and it has 
been found impossible to restore the normal course of the urine on the 
diseased side, nephrectomy should be performed. This may be done 
as a primary operation, if the patient's condition warrants it, or sec- 
ondary to a primary nephrotomy. The adhesions usually present, 
when the sac is large, make primary nephrectomy often a difficult 
-operation. 



CHAPTEE XL VIII 

THE FEMALE URINARY APPARATUS (Continued) 

Renal infections; pathologic changes, symptomatology and diagnosis, treatment 
— Tuberculosis of the kidney ; pathologic changes, symptomatology and diag- 
nosis, treatment — Renal calculi; pathologic changes, symptomatology and 
diagnosis, course and prognosis, treatment — Tumours of the kidneys; pathol- 
ogy, symptomatology and diagnosis, treatment — Operations on the kidney: 
Nephropexy; nephrotomy; nephrectomy. 

In renal infections, as in infections in other tissues of the body, 
the essential etiologic factor is the presence of pathogenic microbes. 
The kidneys, in the performance of their excretory function, are fre- 
quently called upon to eliminate bacteria from the blood current, and 
they may be eliminated in the living state with the urine without the 
kidneys becoming the seat of pathologic changes. In order that the 
kidneys may become the seat of the inflammatory conditions herein 
considered, it is necessary that the bacteria should lodge and develop 
there. There are certain antecedent conditions which favour this lodg- 
ment and development of the microbes. Among these may be men- 
tioned: The ingestion of certain medicaments which produce an active 
hyperemia with exfoliation of cells of the kidney, such as turpentine, 
copaiba, cantharides, etc.; the presence of toxines, the result of bac- 
terial invasion elsewhere in the body; congestion of the kidneys due 
to obstruction to the return circulation or to chilling of the surface of 
the body; internal trauma, due to the presence of a renal calculus or 
other foreign body; external trauma, subcutaneous or direct; and, per- 
haps the most common, obstructions to or interference with the free 
escape of the urine at some point along the excretory channels. While, 
at times, the entire organ may appear to be involved, ordinarily the 
infection is sufficiently limited to warrant the use of certain descriptive 
terms. Thus we may have a circumscribed parenchymatous infection 
producing a 'kidney abscess. When the pelvis is more particularly in- 
volved, it is termed pyelitis. If the infection extends from the pelvis 
along the collecting tubes to the parenchyma, we have a nepliropyelitis 
(pyelonephritis). If, in addition to the infection of the pelvis, we find 
this cavity dilated, it is called nepliropyosis. It should be understood 
that these terms imply simply a difference in degree or extent of in- 
volvement, and that the kind of infection and nature of the process may 
768 



THE FEMALE TJRIXARY APPARATUS 769 

be the same in all. We may likewise find the different conditions coex- 
isting, as for instance, pyelitis, with multiple parenchymatous abscess, 
etc. The routes by which bacteria may reach the kidney are four, 
namely: 1. Through the blood; 2. Along the urinary tract; 3. Through 
the lymphatics by contiguity; 4. Directly from without by trauma. 
Infection through the blood is called hematogenous infection; or some- 
times descending infection, owing to the direction in which the infec- 
tion travels. This is perhaps the most common route in the female. 
The bacteria gain entrance to the blood current from some point of in- 
fection elsewhere in the body and are carried to the kidney, where, 
owing to the presence of some of the antecedent or predisposing condi- 
tions above mentioned, they find lodgment and develop. Hematogenous 
infection may occur in connection with the acute infectious diseases, 
such as typhoid fever, pneumonia, influenza, etc., or in septic conditions 
following confinement or miscarriages. 

Infection from without inward along the urinary tract is called 
ascending infection. The first step in the process is usually a cystitis. 
The changes may remain limited to the bladder for an indefinite time 
as the ureteral orifices offer a considerable barrier to the passage of 
any of the contents, bacteria included, of the bladder into the ureters. 
However, when the bladder becomes distended or contracts vigorously 
to expel its contents through an obstructed channel, or when inflamma- 
tory changes, ulceration, etc., involve directly the ureteral orifices, these 
may become incompetent and permit infection to ascend into the 
ureters. It is unnecessary that the ureter throughout its entire length 
should become involved in the inflammatory process, as it has been 
demonstrated experimentally that bacteria, as well as minute inanimate 
particles, may be carried along the ureter to the pelvis of the kidney 
by antiperistaltic action of the ureter or by propagation along the 
urinary column. 

Even in the presence of a cystitis, it is not always essential that 
the bacteria should reach the kidney through the ureter, as a hemato- 
genous infection may take place from such a local infection as well 
as any other. Propagation by contiguity may take place from the 
bowel in colitis, severe constipation, subcutaneous contusion of the 
bowel, etc., as. when the integrity of the bowel wall has been compro- 
mised in any manner, bacteria may escape through it. 

Infection may also occur as the result of a perirenal abscess due 
to an appendicitis, an infection from the gall bladder, or from a hepatic 
or subphrenic abscess. Direct infection is always due to a penetrating 
wound. 

A variety of bacteria have been found as the infecting agent in 
these cases. In 79 cases reported by Albarran, Schmidt and Aschkoff, 
Wumschein and Savor, the colon bacillus was found pure 48 times, 6 
times associated with Bacillus proteus, and 5 times with the staphylo- 
coccus or streptococcus; with the Staphylococcus pyogenes aureus or the 
streptococcus, 11 times; the Bacillus typhosus, twice; and the Diplococcus 
50 



770 A TEXT-BOOK OF GYNECOLOGY 

pneumoniae, once. Although the gonococcus is unquestionably a com- 
mon cause of the urethritis and cystitis which so often precede the 
renal infection, it does not appear to have been frequently found alone 
in the kidney. From the foregoing, it will be seen that the colon bacil- 
lus is the organism most commonly found in these cases, and this fact 
indicates the frequency with which the infection proceeds from the 
intestine. In the etiology of nephropyosis, all those conditions which 
lead to dilatation of the pelvis, mentioned under nephrydrosis, are 
equally active, the only difference being the addition of an infection. 

The pathologic changes vary somewhat according to the manner of 
infection. In hematogenous infections, there may be one or more ab- 
scesses of varying size due to the lodgment of septic emboli, and pre- 
senting the same characteristics as pysemic abscesses in other organs 
of the body. Again, there may be a diffuse involvement of the kidney 
with masses of microbes found in the glomeruli and about the secret- 
ing tubes, which lead to swelling, coagulation necrosis, and exfoliation 
of the cells with peripheral leucocytic infiltration. When the infection 
extends from the pelvis, the microbes are found ascending the collect- 
ing tubes, often reaching as far as the secreting portion, producing 
the same destructive effect on the epithelial cells, and leading to in- 
creased interstitial connective-tissue formation. 

In pyelitis, the mucosa of the pelvis is thickened and reddish or 
grayish in colour. Circumscribed denudations or superficial ulcerations 
may, at times, be seen particularly about the tips of the pyramids. 
The mucous membrane is often covered by a thin layer composed of 
pus cells, exfoliated epithelia, microbes, mucus, etc., which gives to 
the membrane a smooth velvety feel to the touch. 

In nephropyosis, in addition to the changes in the mucosa already 
noted, the pelvis is found more or less dilated. The dilatation may be 
slight, or so great that the kidney tissue is compressed and flattened out 
so that the entire organ forms but a large pus sac. Usually, the dilata- 
tion is but moderate, and the calyces form pouches or pus sacs com- 
municating with the pelvis, the pyramids being so compressed as to 
present the appearance of trabecular extending through the cavity. 
Concretions are often found in the calyces or pelvis. A calyx may be- 
come shut off from the pelvis, thus forming a circumscribed abscess, 
and independent abscesses in the kidney tissue which do not communi- 
cate with the pelvis are common. 

When the infection has been an ascending one, the ureter often 
shows marked changes due to chronic inflammation. Its walls are much 
thickened, it becomes dilated, elongated, and tortuous, and reduplica- 
tions of the mucosa lead to the formation of valvelike strictures. Peri- 
nephritis with abscess formation is quite common, and, in nephropyosis, 
adhesions to surrounding parts the rule. 

Symptomatology and Diagnosis. — The symptoms may be arranged 
under three heads: 1. General; 2. Local; 3. Urinary Changes. The 
onset may be acute or slow and insidious. When renal abscesses 



THE FEMALE URINARY APPARATUS 771 

occur in the course of a pyaemia, the condition is usually unrecognised 
owing to the severity of the general disorder, and the abscesses are 
found only at the autopsy. In an acute case following general ex- 
posure, or after confinement, or from a sudden extension of an infection 
from the bladder, the temperature will be found elevated, 101° to 103° 
F., with the usual symptoms accompanying fever. Locally, there will 
be pain in the lumbar region with distinct tenderness as the kidney 
is grasped between the two hands. In many cases of ascending infec- 
tion, the kidney becomes involved so insidiously that it is frequently 
impossible to tell just when this organ began to be affected. There 
will be an elevation of a degree or two in the temperature, particu- 
larly toward evening, with gradual loss of weight and deterioration of 
the general health. The kidney, if palpable, will usually be felt to be 
slightly enlarged and tender on pressure. There may be pain in the 
region of the kidney, at times simulating mild attacks of renal colic. 
Frequent urination is the rule, and it may be present even when there 
is no involvement of the bladder. Changes in the character of the 
urine are always present. It will be found to contain a variable amount 
of pus and albumin, numerous bacteria, and epithelial cells from the 
pelvis as well as from the tubules, should these be involved. Cylin- 
droids and casts will be present if the kidney substance is affected, but 
may be absent when the infection is limited to the pelvis. The reaction 
of the urine will depend upon the kind of microbe present. The urine 
may remain acid throughout when the infection is due to the colon 
bacillus as well as to some varieties of streptococcus, but the usual 
Staphylococcus pyogenes aureus and the proteus decompose urea, thus 
rendering the urine alkaline. It then often contains the common triple 
phosphate crystals. There is nothing characteristic about the pus or 
the epithelial cells to indicate their origin from the pelvis of the kidney. 
When the origin of these pathologic products is in doubt, it will be 
necessary to collect the urines directly from the kidneys by catheteriza- 
tion of the ureters, or by the use of the urine segregator. 

In nephropyosis the appearance of pus in the urine may be inter- 
mittent. If the affection is unilateral, the opposite kidney in the in- 
terval may furnish perfectly normal urine. The kidney is always more 
or less enlarged in nephropyosis, and, at times, the tumour reaches con- 
siderable dimensions. The diagnostic points which indicate the renal 
origin of the tumour have already been referred to under Methods of 
Examination. 

The course of these infections is variable. Many cases following 
confinement recover entirely. In other cases, the pus may disappear 
but the bacteria remain, leaving a condition of simple bacteriuria. If 
the affection is unilateral, it may persist in a mild way for several years 
without materially injuring the general health, but the opposite kidney 
is always liable to become affected, which adds materially to the serious-, 
ness of the condition. When abscesses develop in the kidney substance 
or in the perirenal tissues, death may take place from sepsis, or from 



772 A TEXT-BOOK OF GYNECOLOGY 

uraemia when a considerable amount of the kidney tissue is destroyed. 
The prognosis is also somewhat influenced by the kind of infection 
present, a colon-bacillus infection, for instance, being more favourable 
than one due to the streptococcus. 

In the treatment, due consideration should be given to antecedent 
conditions, as cystitis, pelvic infections, primary perinephric abscesses, 
intestinal complications, etc. For the renal affection itself, the admin- 
istration of large quantities of distilled water to induce free flushing 
of the kidneys is of advantage. At the same time may be given some 
of the antiseptic agents which are eliminated with the urine, and of 
these the formalin compounds, such as urotropin and cystogen, appear 
to be the most useful. Salol, boric acid, and benzoic acid, are also, at 
times, of value. Direct treatment of the pelvis in pyelitis by irrigation 
through the ureteral catheter, as practised by Kelly, Casper, and others, 
has given good results in some cases. The solutions used are boric 
acid; dilute nitrate of silver 1 to 1,000; and bichloride of mercury 
1 to 150,000 gradually increased to 1 to 16,000 (Kelly). They should 
be used warm and with great care. This treatment does not appear ad- 
visable in cases with fever (Casper), as chills with high temperature 
may follow. Should these means fail to give relief, nephrotomy with 
drainage through the lumbar region may be tried. At the same time, 
all complicating conditions should be relieved, if possible, such as 
removal of calculi, correction of strictures or obstructions of the 
ureter, fixation of movable kidney, etc. As a last resort, and only when 
it is positively known --that the opposite kidney is normal, may nephrec- 
tomy be performed. 

Tuberculosis of the Kidney. — In acute miliary tuberculosis the kid- 
neys may be involved in connection with the other organs of the body, 
but as such cases have no special interest to the surgeon, they will not 
be further considered here. 

Surgical tuberculosis of the kidney may exist as a primary affection, 
or it may be secondary to tuberculosis of other portions of the urinary 
tract or of contiguous structures. In the primary variety, it is well 
understood that an infection atrium must have existed at some pre- 
vious time through which the tubercle bacillus gained entrance to the 
body, and, in many of these cases, a latent tuberculous focus is found 
in the shape of an old tuberculous bronchial or mesenteric lymph gland. 
The bacilli are carried to the kidneys by the blood and the process is 
therefore a pure hematogenous infection. 

Women are more commonly affected than men in the proportion of 
29 women to 14 men (Turner); 148 women to 55 men (Albarran); and 
73 women to 59 men (Bangs); a total of 378 cases, with 250 women, 
or 66 per cent. Almost any age may be affected, but 75 per cent of 
the cases occur between the ages of twenty and forty years. The kidney 
is primarily affected in a majority of the cases, and usually, at first, 
but one organ is involved. Later the opposite organ may become 
affected. 



THE FEMALE URINARY APPARATUS 



73 




Fig. 311. 



' Tuberculous abscesses are produced. "' 
— Harris. 



Tuberculosis of the kidney secondary to involvement of the lower 
urinary tract, is not so common in women as in men. in whom we may 
have a primary affection of the 
prostate, seminal vesicles, epi- 
didymis, etc. A tuberculous 
abscess originating in the ver- 
tebrae (Pott's disease) or from 
the bowel, may extend to and 
involve the kidney secondarily. 
Pathologic Changes. — The 
most common form observed is 
the large tuberculous nodule. 
Such a nodule is made up of a 
conglomerate mass of histo- 
logic tubercles, forming a 
grayish or yellowish mass vary- 
ing from 0.5 centimetre to 2 
or 3 centimetres in diameter. 
Often, there is but a single 
nodule, when it commonly oc- 
cupies one or the other pole, 
but they may be multiple and 
disseminated throughout the 
kidne}'. The nodules undergo 

the usual changes so characteristic of tuberculous tissue, namely casea- 
tion, and softening or liquefaction. In this manner, tuberculous ab- 
scesses are produced which 
may rupture into the pelvis 
or on the surface of the kid- 
ney into the perinephric tis- 
sue (Fig. 311). The walls of 
such abscesses become lined 
with the usual tuberculous 
granulations which show oc- 
casional giant cells (Pig. 
312), and the surrounding 
kidney tissue shows the ordi- 
nary inflammatory changes. 
In tuberculous pyelitis, small 
tubercles may be found dis- 
seminated more or less thick- 
ly in the mucosa. As these 
soften and break down, small 
ulcers are formed. A sin- 
gle small tuberculous ulcer 
on one of the pyramids may give rise to pronounced hematuria, 
which may persist for a long time without any other symptoms being 




Fig. 312.—" The walls of such 
occasional ffiant cells. 



>cesses . . . show 
Harris. 



774 A TEXT-BOOK OF GYNECOLOGY 

present. The ureter may become involved with the production of 
caseous nodules or masses, which may interfere with the escape of the 
urine and thus lead to the development of a tuberculous nephropyosis. 
A mixed infection in these cases is very common, the ordinary pyogenic 
organisms being the ones most frequently found. In almost all cases 
of tuberculosis of the kidney that have existed for any length of time, 
marked changes occur in the perirenal tissues. Some of the fat be- 
comes absorbed, while the connective tissue is greatly increased in 
amount. The entire fatty capsule thus becomes converted into a 
dense, hard mass, surrounding the kidney, and so intimately attached 
to the adjoining structures, particularly the colon and great vessels, 
that it is often impossible to detach it from them without great danger 
of injury. This perinephritis fibrosa may form a tumour of consider- 
able size easily palpable through the abdominal wall. The tuberculous 
kidney occupies the interior of this dense capsule, and while it is, at 
times, difficult or impossible to remove the capsule itself, the kidney 
is fortunately usually easily enucleable from its centre. Provided all 
the tuberculous tissue is removed with the kidney, this dense peri- 
nephric mass may entirely disappear by absorption. When numerous 
abscesses develop, rupturing into the pelvis or into each other, the en- 
tire kidney substance may practically be destroyed, and nothing remain 
but abscess cavities whose walls are lined with tuberculous granula- 
tions. The lymph glands about the hilum of the kidney may become 
tuberculous, forming distinct separate nodules. 

Symptomatology and Diagnosis. — The onset of tuberculosis of the 
kidney is often obscure. One of the most frequent symptoms in the 
early stage is hematuria. This may be in quantity scarcely sufficient 
to give colour to the urine, or quite profuse, and it may persist for some 
time. It usually appears spontaneously, being discovered by the pa- 
tient by accident, and is not materially influenced by exercise or repose. 
If the hemorrhage is profuse enough, clots may form, the passage of 
which along the ureter may give rise to severe pain. Such clots formed 
in the ureter have a characteristic wormlike appearance when passed. 
In the later stages, hematuria is less common. Frequent urination, 
accompanied with more or less pain, is a very common symptom, and 
may be present when there is no trouble whatever with the bladder. 
It is then a reflex or irradiation symptom, and is of great diagnostic 
value in the early stages. More or less pain or ache in the lumbar 
region is the rule, and frequently sharp pains of short duration may 
be felt, which resemble mild renal colic, but which may occur when no 
solid substance passes the ureter; they are then, probably, in the nature 
of neuralgia of the ureter. The kidney is usually somewhat enlarged 
and tender on pressure. Changes in the urine are always sooner or 
later present, but during the early stage they may not be very marked. 
Blood, as already mentioned, may be present. It may be so slight in 
amount as to require the microscope for its detection, or so profuse 
that the urine may appear like blood. More or less pus is always pres- 



THE FEMALE URINARY APPARATUS 



< (O 



ent, together with epithelial cells from the pelvis and tubules. Albu- 
min is found, and in excess of what it is usual to ascribe to the pus 
present. While casts are not essential to the tuberculous process, a 
few can usually be found owing to circumscribed patches of ne- 
phritis. 

The above-mentioned urinar}- changes are not characteristic of 
tuberculosis but are common to pyelitis or nephropyelitis whatever the 
nature of the infecting agent may be. The detection of the tubercle 
bacillus in the sediment, therefore, is necessary to an absolute diag- 
nosis. 

In most cases the bacillus can be found, if sufficient urine is sub- 
mitted to the centrifuge and the sediment properly stained. It may 
be necessary to examine a number of specimens before iinding any, 
and sometimes one fails even after repeated examinations. In these 
cases, inoculation experiments may demonstrate the tuberculous nature 
of the affection. It is quite probable that a purulent urine, acid in 
reaction, in which none of the ordinary bacteria are present, comes 
from a tuberculous kidne} T , even when no tubercle bacilli can be found. 
In later stages mixed infection may occur and the urine may be found 
to contain the ordinary pyogenic microbes as well as the tubercle bacil- 
lus. During the early stages, there is usually no fever, but, later, 
a rise of from one to two degrees is noted toward evening. 

The prognosis of tuberculosis of the kidney in general is not good, 
and when both kidneys are involved it is certainly bad, although re- 
covery is possible. In primary unilateral tuberculosis, where the kid- 
ney involved is removed, the prognosis is very good. Harris has 
patients living five and six years after nephrectomy for unilateral tuber- 
culosis, who are in perfect health. When the bladder becomes affected 
and mixed infections are present, the prognosis is again bad. 

Treatment. — While it can not be denied that tuberculosis of the 
kidney may be recovered from spontaneously or under treatment, still 
the probabilities of such a favourable termination are too remote to 
be depended upon. In primary unilateral tuberculosis, the rational 
treatment is nephrectomy. Even the presence of beginning trouble in 
the apex of the lungs or of albuminuria from the opposite kidney is not, 
in itself, a contraindication to nephrectomy in these cases, as, after 
removal of the principal and primary focus, these secondary conditions 
may clear up and disappear. Unless the bladder is actually invaded 
by the tuberculous process, the vesical symptoms, so common when the 
kidney is involved, may also entirely disappear after removal of the 
kidney. It is doubtful if resection of the kidney, as has been done, is 
advisable in tuberculosis, because even in the nodular variety, it is im- 
possible to tell whether there may not be small impalpable nodules in 
the apparently healthy portion, or to what extent the pelvis may be 
involved, thus permitting reinfection. 

When the kidney infection is secondary to advanced tuberculosis 
in other portions of the body or when both kidneys are extensively 



776 A TEXT-BOOK OF GYNECOLOGY 

involved, nephrectomy should not be done, but, even here, nephrotomy 
for the purpose of draining large purulent accumulations, may be: 
advisable. In all cases, proper hygienic, climatic, and medicinal meas- 
ures, should be instituted. 

Renal Calculi. — Kidney stones are due to the precipitation and 
agglutination of salts normally or abnormally present in the urine. 
These two conditions are absolutely necessary. The substance must 
not only be precipitated, but the crystals or particles forming it must 
cohere or become agglutinated to form a mass. Various factors are- 
instrumental in causing precipitates in the urine, such as changes in 
the reaction and temperature, variations in the relative or absolute pro- 
portion of the salts present, and the presence of abnormal constituents. 
These conditions are brought about by the character and amount of 
food and drink taken, the nature of the digestive changes, individual 
peculiarities of internal metabolism, etc. 

The fact, however, that uric acid, oxalates, urates, phosphates, etc.,. 
may be passed suspended in the urine for almost indefinite periods of 
time without calculi appearing, shows conclusively that other condi- 
tions are essential to stone formation. Among these conditions, may 
be mentioned a nucleus or centre about which the salts may become 
deposited. The importance of a nucleus has been mentioned by a num- 
ber of writers. Ebstein considers that the exfoliated epithelial cells 
from the tubules or pelvis often form nuclei of stones, but in acute 
nephritis of scarlatina, where exfoliation is so marked, stones do not 
occur. Blood clots are likewise often mentioned in this connection, 
but a blood clot has remained in the kidney a year and a half (Maas) 
without giving rise to the slightest deposit about it. We must, there- 
fore, search further for a common cause. This has been suggested by 
Gallippe to be the presence of microbes. Harris, in a recent article on 
Eenal Calculi {Journal of the American Medical Association, March 17, 
1900), has shown by experimental and clinical evidence the causal rela- 
tion between the presence of microbes in the urine and stone forma- 
tion. It has long been known that stones frequently develop second- 
arily to suppurative infections of the kidneys, and, for this reason, 
kidney stones have been classed as primary, or those developing in 
kidneys not the seat of surgical infections, or, in other words, of non- 
microbic origin; and secondary, or those developing in kidneys the 
seat of surgical infections, and therefore of microbic origin. Harris 
has shown, however, that so-called primary stones are likewise of mi- 
crobic origin. 

The facts upon which this statement rests, which are elaborated 
in the article mentioned, may be briefly stated as follows: Precipita- 
tion alone does not cause stone. Foreign bodies, such as exfoliated 
epithelial cells, blood clots, or those introduced experimentally from 
without, do not cause stone so long as they remain free from microbes. 
The kidneys frequently eliminate microbes with the urine without 
themselves becoming the seat of microbic invasion. These microbes- 



THE FEMALE URINARY APPARATUS 777 

may develop in the urine in the pelvis and cause the precipitation of 
certain salts. The character of the precipitate depends, not entirely 
upon the composition of the urine, but also upon the kind of microbe 
present. The microbes, in developing, form zoogioea masses, in and 
about which the precipitate takes place. The agglutination of the 
particles by the zoogioea mass forms the nucleus or starting point of 
the stone. Such zoogioea masses have been found clinically in the urine. 
The microbe most frequently found in the urine is the colon bacillus. 
It grows in acid urine, and under proper conditions causes the pre- 
cipitation of uric acid or acid urates. The most common primary stone 
is composed of uric acid and the urates. Microbes have been found in 
the centre of so-called primary stones. From the clinical side, we find 
stones frequently preceded by a history of acute or chronic intestinal 
disorders; of suppurative lesions of the skin; of acute infectious dis- 
eases, as influenza, pneumonia, typhoid fever, etc.; and women very 
commonly date the beginning of their trouble from a confinement or 
imperfect puerperium. These conditions are all such as readily account 
for the presence of microbes in the urine. These facts briefly men- 
tioned lead Harris to state that practically all kidney stones are of 
microbic origin. The only value, therefore, of the classification of 
stones into primary and secondary is, that the former may occur in a 
kidney which is not itself the seat of microbic invasion, while the 
latter are always secondary to an infective process in the kidney. Of 
the primary stones, from 75 to 80 per cent are composed of uric acid 
and the urates. Next in frequency, come oxalate of lime and, rarely, 
dibasic phosphate of lime. Very rarely, stones have been found com- 
posed of cystin, xanthin, indigo, cholesterin and fibrin. The etiology 
of these is not fully understood. Those of the uric-acid group are yel- 
lowish or brown in colour, rather smooth, or even polished if multiple, 
and often somewhat flattened and oval in shape. Oxalate stones are 
hard, dark in colour, more or less spherical in shape, and rough or 
nodular on the surface. 

Secondary stones are formed of the decomposition products, such as 
ammonio-magnesium phosphate, phosphate and carbonate of lime, and 
urate of ammonium. They are usually whitish in colour, irregular in 
outline, present a rough granular surface, and are fragile. Stones are 
frequently not of uniform composition, but made up of different layers. 
It is very common to find primary stones incrusted with phosphates 
after the kidney has become septic. Stones may be single or multiple. 
Harris has removed as many as 52 well-formed bright, polished, uric- 
acid stones, from a kidney with a history of trouble extending over 
twenty-five years. In size, they may vary from small granules to a 
large stone filling the entire pelvis, with irregular branches extending 
into the calyces and upper end of the ureter, and weighing several 
ounces. While they usually occupy the pelvis or calyces, stones may be 
found embedded in the parenchyma of the organ. An important point 
is the frequency with which stones are found simultaneously in both 



I I 



A TEXT-BOOK OF GYNECOLOGY 



kidneys. This lias been variously estimated, but about 1 case in 5 
or 6 is perhaps near the average. Those of any age may be affected, 
but from thirty to sixty years is the most favourable time. 

Pathologic changes always develop sooner or later in kidneys the 
seat of stone. These take the form of chronic nephritis, the interstitial 
changes usually being most marked. The changes may be so extensive 
that the organ becomes greatly atrophied and its excreting function 
much reduced. The stone may be so located as to obstruct the free 
escape of urine from the pelvis, thus giving rise to a nephrydrosis. 
Even in so-called primary stones, the constant trauma which they inflict 
upon the interior of the kidney renders the organ particularly liable 
to infection, and, in fact, this almost always, sooner or later, takes 
place. There are now added all the additional dangers of a septic 
kidney: Pyelitis, nephropyelitis, nephropyosis, parenchymatous and 
perinephric abscesses, etc. 

Symptomatology and Diagnosis. — The symptoms may be discussed 
under three heads: 1. Pain, including tenderness; 2. Changes in the 
character of the urine; 3. Abnormal urination. 

The pain is of two kinds: Acute intermittent paroxysms, which are 
so familiar under the name of renal colic, and the dull more or less con- 
stant ache in the lumbar or lateral abdominal region. The passage of a 
small stone along the ureter gives rise to an attack of typical renal colic, 
but similar attacks, perhaps somewhat less severe, may occur Avithout the 
passage of a stone. The more or less constant pain is usually increased 
by exercise (driving or riding) that jolts the body, and may radiate in 
almost any direction, downward to the bladder, upward to the costal 
region, across the abdomen, or into the thigh. Persistent pain in the 
latero-lumbar region or radiating in any direction from this region, 
which is otherwise unaccountable for, should always excite a suspicion 
of renal calculus. Tenderness over the region of the kidney or along the 
ureter is often present, and may be of some importance in determining 
the side affected. One of the most peculiar features of the pain is the 
fact that rarely it may be located on the side of the body opposite to the 
kidney affected (Tuckerman, Battle). 

Under the head of urinary changes may be mentioned the presence 
of blood, pus, epithelial cells, crystals, and bacteria, in the urine. The 
character of the hematuria is of some diagnostic importance. A sudden 
macroscopic hematuria is probably not due to a stone in the kidney. 
We more commonly meet with microscopic hematuria. The rather 
constant presence of a few red blood cells in the urine, discovered only 
with the microscope, which quantity of blood may be increased by 
exercise such as -dancing, riding, driving, etc., to visible proportions, 
is quite characteristic of kidney stone. The hemorrhage is due to the 
local action of the stone on the walls of the cavity which contain it, 
and is proportionate to the roughness of the surface of the stone and 
to its degree of mobility. A small movable stone may excite consid- 
erable bleeding and a very large fixed one almost none. Pus in the 



THE FEMALE URINARY APPARATUS 779 

urine is simply indicative of an infection of some portion of the urinary 
tract. Its exact point of origin must be known to give it a more specific 
significance. With the exception of the secreting cells of the kidney, 
the epithelial cells lining the urinary tract do not present local char- 
acteristic differences. The rather frequent or persistent presence of 
particular crystals in the urine in considerable amount, may give a hint 
as to the character of the stone present. Bacteria in the urine are of 
diagnostic importance, aside from determining the kind of infection, 
only when taken in consideration with, other symptoms. It will be 
seen, therefore, that the urinary changes in themselves are not diag- 
nostic of renal calculus, for the simple reason that it is impossible to 
tell from their mere presence alone from what part of the urinary tract 
the pathologic products have had their origin. In order to be certain 
of their origin, it is often necessary to collect the urines directly from 
the kidneys, either by catheterizing the ureters, or by the use of the 
urine segregator. While a stone that gives rise to pain almost always 
gives rise to pathologic products in the urine, it should not be forgotten 
that a stone fixed in the parenchyma of the kidney may give rise to 
pain for years without the appearance of any pathologic elements 
in the urine (Miiller). 

Abnormal urination, in the shape of increased frequency or pain, 
is sometimes present, but is not in itself indicative of stone. At times 
a stone lodged in the ureter, and rarely one in the pelvis, may be de- 
tected by the introduction of a ureteral bougie. Keely has recom- 
mended that the tip of the bougie be covered with wax in order that it 
may receive impressions if brought in contact with a rough stone. The 
use of the X-ray is often of great value in the diagnosis of kidney 
stones. A well-defined positive shadow is, under proper conditions, 
quite certain evidence, but negative evidence can not at present be 
considered conclusive. 

Course and Prognosis. — A stone may exist in the kidney for years 
without giving rise to serious symptoms, but this is the exception. The 
chronic nephritis which, to some extent, always follows the presence of 
a stone, may produce such atrophy as to practically destroy the secret- 
ing function of the organ. When infection takes place, the patient is 
subject to all the dangers and sequela? of a septic kidney. One of the 
most dangerous complications which may occur is sudden suppression 
of the urine or calculous anuria. This is due to a stone suddenly 
blocking up the ureter. It is more likely to occur when both kidneys 
are affected. In unilateral stone, the suppression in the opposite 
kidney is due to reflex action but, in these cases, it is probable that 
the stoneless kidney is always the seat of pathologic changes, such as 
chronic nephritis, atrophy, cystic degenerations, etc. 

In making the diagnosis, it is often difficult to determine on which 
side the obstruction has taken place. Previous knowledge of the case 
may be of assistance, otherwise one must depend upon the history of 
pain and the presence of tenderness. The danger of this complication 



780 A TEXT-BOOK OP GYNECOLOGY 

will be appreciated when it is stated that the mortality in cases not 
operated on is about 70 per cent. 

Treatment. — The acute paroxysms of renal colic should be treated 
by the hot bath for its relaxing effect, and the administration of hypo- 
dermatic injections of morphine. It may be necessary at times to resort 
to the inhalation of chloroform. The possibility of dissolving a stone 
once formed in the kidney is quite remote. The administration of 
large quantities of distilled water for a considerable period of time is 
perhaps the most beneficial. The common mineral waters and alkaline 
springs recommended for this purpose are usually without benefit, and 
may even cause an increase in the size of the stone by deposits induced 
by the excessive alkalinity of the urine maintained (Rovsing). Her- 
mann recommended the use of glycerine in doses of 50 to 100 grammes 
a day, but Senator cautions against its use on account of the hematuria 
which it may induce. When the kidney is septic, urotropin or cystogen 
in doses of half a gramme (about 1\ grains) three or four times daily, 
will be of benefit in so far as they inhibit the growth of the microbes, 
and thus prevent the decomposition of the urine. 

While these means may aid somewhat in washing out gravel or small 
stones from the kidney, when a stone too large to pass the ureter once 
forms, relief is only to be expected through surgical intervention. Nor 
should operation be delayed, for the dangers of a septic kidney are 
great, and the longer a stone remains, the more pronounced are the 
changes produced in the kidney. The choice of operation will be be- 
tween nephrolithotomy, nephrostomy and nephrectomy. In an aseptic 
kidney, with a so-called primary stone, nephrolithotomy is the proper 
operation. In the presence of sepsis, with pyelitis, nephropyosis, or 
abscesses in the parenchyma, in addition to the removal of the stones, 
drainage will have to be established (nephrostomy). The ureter should 
always be examined and its patency determined. Should obstruction be 
found, it should be removed, if possible, and a free communication 
between the pelvis and ureter established. Should this be neglected 
or impossible of accomplishment, a permanent urinary fistula is almost 
certain to follow the operation. Primary nephrectomy for stone is 
seldom advisable. The opposite kidney must be known to be healthy, 
and the affected one so destroyed as to be beyond repair, to warrant the 
operation. It is better to do a primary nephrostomy with a secondary 
nephrectomy should it be necessary. The combined mortality of the 
two operations is less than that of primary nephrectomy under the 
conditions usually presented in bad cases of septic nephrolithiasis. 

In anuria from calculus an attempt may be made, under favourable 
circumstances, to dislodge the stone by means of the ureteral bougie. 
Should this fail, nephrostomy should be performed. In case no stone 
is found in the first kidney operated on, the other should be opened 
at once. 

Tumours of the Kidney. — When speaking of tumours of the kidney, 
we must confine ourselves to true neoplasms, to the exclusion of such 



THE FEMALE URINARY APPARATUS 781 

conditions as nephrocystosis, nephropyosis, etc. These, while giving 
rise to a " kidney tumour " in a purely clinical sense, are, of course, not 
true new growths in the strict application of the word. What we find 
in the older medical literature on renal tumours is almost entirely 
worthless, since, in these reports, every swelling is spoken of under the 
head of kidney tumour, and even the true neoplasms, in the absence of 
a proper microscopic examination, were generally classified very inaccu- 
rately. Consequently, clinical indications were drawn without proper 
basis and practical conclusions were utterly unreliable. Only the last 
few years have brought some system into the unsatisfactory chaos. In 
certain respects, the permanent kidney is a very peculiar organ. It is 
preceded in embryonic development by two temporary organs, the 
pronephros and the " urniere," or Wolffian body. These structures and 
attached portions of the suprarenal capsule give rise to embryonic rem- 
nants which may become included in the permanent kidney and fur- 
nish a fertile matrix for subsequent neoplastic formations. 

Pathology. — All kinds of tumours may develop in the kidney. Be- 
side the ordinary types of connective tissue and epithelial neoplasms, 
benign as well as malignant, we find in the kidney two peculiar kinds 
of tumours which are of particular pathological interest, the hyper- 
nephroma and the mixed renal tumours. 

Keoplasms of the kidney, according to some authors, occur more 
frequently in the male than in the female. This, however, is denied by 
Kelynack {Renal Growth, Edinburgh and London, 1898), whose col- 
lection of 112 cases shows 70 tumours in males and 72 cases in females. 
Birch-Hirschfeld affirms that in children renal neoplasms are more 
frequently found in the female than in the male sex. Renal tumours 
are found at all ages. The greatest number occur before the tenth year 
of life. Of White and Martin's 459 tabulated cases, 157 were observed 
in infants and children up to two years of age. In size, these tumours 
vary from small nodules to growths of from 30 to 40 pounds in weight. 
In shape, renal tumours often preserve the outlines of the kidney, even 
when large. At other times, the kidney shape is entirely lost and the 
mass becomes irregular and nodular. Of the benign connective-tissue 
tumours, the fibroma is generally small, hard and round, or elliptical. 
Occasionally larger fibromata have been observed. The small fibromata 
frequently found on post-mortem examination are most probably not 
true neoplasms, but the remnants of focal interstitial inflammatory 
processes. Lipomata of the kidney are rare, but a small number of cases 
has been reported. Angeiomata have been sometimes found, but most 
cases formerly described as such were very vascular sarcomata. 

Sarcoma is probably the most frequent of all kidney tumours. It 
is found in fcetal life, in infancy and childhood, and in adolescence. 
The importance and frequency of sarcoma of the kidney in childhood 
has been pointed out by Jacobi in a number of articles. Herzog be- 
lieves that renal sarcoma is more frequently found in female than in 
male children. Renal sarcoma occurs as a capsular, a parenchymatous, 



782 



A TEXT-BOOK OF GYNECOLOGY 



and a hilum growth. It may also primarily arise in the suprarenal 

capsule, to grow secondarily into the kidney. Histologically, we find 

round and spindle-celled 
growths, or the cells are 
of mixed type and char- 
acter. The sarcoma de- 
picted in Fig. 313, re- 
moved by operation from 
a child nine months old 
by Harris, and studied as 
to its histology by Her- 
zog, was of such a mixed 
type and showed very 
heterologous connective- 
tissue elements. The pro- 
liferation of tumour cells 
is well shown in a section 
(Fig. 314) prepared by 
Herzog. It was for- 
merly believed that ade- 
nomata were among the 
most frequent, if not the 
most frequent, of renal 
tumours. But most of 
the cases formerly re- 
ported as adenomata did 
not belong to this class of 

neoplasms, but to the hypernephromata (see postea.) True nonmalig- 

nant adenomata occur as nodules varying in size from that of a millet 

seed to that of a hazelnut. 

They are sharply defined 

from the surrounding normal 

tissue. Histologically, they 

show either an alveolar or a 

tubular type. It is sometimes 

difficult to distinguish be- 
tween a benign adenoma and 

an early adenocarcinoma, 

and the more so since some 

renal adenomata primarily 

benign, undergo secondary 

malignant degeneration. 

Kelynack describes as 

such forms the malignant 

papuliferous cystadenoma of 

the kidney. Epithelial neo- 
plasms which, from the very 




Fig. 313. — ■" The sarcoma removed by operation from a 
child nine months old by Harris." — Herzog. 




Fig. 314— u The proliferation of tumour cells is 
well shown in a section."— Herzog. 



THE FEMALE URINARY APPARATUS 



783 



start, are malignant in character, in other words typical carcinomata, 
are not common in the kidney. They may be either soft or hard, 
and often lead to considerable enlargement of the kidney affected. 
An embryonal renal adenosarcoma, mixed tumour, 59 centimetres in 
circumference, was removed by Dr. Denslow Lewis from a child sixteen 
months old (Fig. 315). 

The histogenesis of 
mixed tumours of the kid- 
ney, or embryonal renal 
adenosarcomata, was 
cleared up a few years ago 
by Birch-Hirschfeld, and 
Herzog was the first to 
take up this subject in 
the English language. 
(Herzog: The Peculiar 
Mixed Tumours of the 
Kidney, Chicago Medical 
Recorder, 1899; Herzog 
and Lewis : Embryonal 
Eenal Adenosarcoma, 
American Journal of the 
Medical Sciences, June, 
1900.) These mixed renal 
tumours occur very early 
in life, frequently during 
the first years, though a 
very few cases have been 

reported in adults. They grow very rapidly, speedily lead to general 
malignant cachexia, and destroy the life of the patient either with or 
without the formation of metastases. They generally first attract atten- 
tion by the increasing size of the abdomen. These tumours always de- 
velop inside the kidney. The kidney tissue proper, however, does not 
take part in the proliferating neoplastic processes but becomes com- 
pressed by the new growth and the urinif erous tubules, and their lining 
epithelia disappear in consequence of pressure atrophy. What is left of 
the kidney sometimes sits on the tumour like a flat cap. These malig- 
nant renal tumours are so heterologous in their histology that they have 
been described as carcinomata, sarcomata, endotheliomata, rhabdomyo- 
mata, and under a variety of compound names. The feature common to 
them all is the fact that they present a mixture of epithelial, adenoma- 
tous, and connective-tissue elements, all of which are proliferating in a 
most extensive embryonal manner (Fig. 316). 

These tumours very frequently contain striated muscle fibres which 
sometimes are so numerous that such new growths were formerly de- 
scribed as rhabdomyomata or rhabdomyosarcomata. Fig. 317 is from a 
section of mixed tumour, the rhabdomyomatous part showing embryonal 




Fig. 



315. — "An embryonal renal adenosarcoma 
removed bv Dr. Denslow Lewis." — Hekzog. 



784 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 316 



striated muscle cells. They do not tend to form early metastases, but, 
on the contrary, lead to the latter only after the growth has become so 
very large that it has broken by pressure through the capsule. The 

neighbouring lymphatics are 
not affected even when the 
epithelial type predominates. 
Several theories have been 
advanced as to the origin 
and the histogenesis of these 
mixed tumours. Herzog (loc. 
cit.) has advanced the follow- 
ing theory: 

" The nephrotome in 
early embryonic develop- 
ment is not cut off at the 
normal site, but in such a 
manner that a part of the 
myotome is severed from the 
main mass and remains in 
conection with the nephro- 
tome. The separation may 
take place so that only a part 
of the myotome proper is cut 
off, or a part of the sclerotome may likewise be taken along. If the former 
is the case, we have the matrix for striated muscle fibres only; if the latter 
occurs, we have also the matrix 
for cartilage. If, now, we as- 
sume that a part of the ne- 
phrotome (Wolffian body) to 
which tissues of the myotome 
have become adherent by an 
abnormal process of embry- 
onic separation, becomes in- 
cluded in the permanent kid- 
ney, we have a matrix con- 
taining all those embryonic 
elements which occur in the 
mixed renal tumours, name- 
ly, striated muscle fibres, car- 
other connective-tis- 
elements, and epithelial 



Ihey present a mixture of epithelial, 
adenomatous, and connective-tissue elements." — 
Harris (page 783). 



tilage 

sue 

glandular structures. The 

latter, of course, are derived 

from the excretory tubules of 

the nephrotome." 

Hypernephromata. — Certain 




Fig. 317. — ". . . A section of mixed tumour, the 
rhabdomyomatous part showing embryonal stri- 
ated muscle cells." — Herzog (page 783). 

renal tumours described formerly as 
lipomata or adenomata are now known to be derived from supra- 



THE FEMALE URINARY APPARATUS 



'85 



renal tissue misplaced within the kidney during embryonic devel- 
opment. These tumours were called by Grawitz, who first recognised 
their true nature, Struma suprarenalis lipomatodes aberrans. They 
are now generally known under the name of hypernephromata 
(Fig. 318). 

The included aberrant suprarenal tissue may develop into non- 
malignant tumours. Even the latter are generally slow in their growth, 
but they usually give rise to metastases. These new growths generally 
give rise to a dull pain, 
and frequently produce 
periodical intermittent 
hematuria in consequence 
of their great vascularity. 

Histologically, they 
show a tissue which is an 
atypical imitation of the 
structure of the supra- 
renal capsule. The tu- 
mour cells are particularly 
often found in an arrange- 
ment very much similar to 
that seen in the zona fas- 
ciculata of the adrenal 
gland (Fig. 319). The 
cells show a universal 
marked tendency to un- 
dergo fatty degeneration, 
and glycogen is likewise 
often found (Fig. 320). 

Symptomatology a n d 
Diagnosis. — The symp- 
toms of renal neoplasms 
are very meagre, so much 

so, that it is usually impossible to make a diagnosis as to the par- 
ticular kind " of tumour present. Nearly 50 per cent of the new 
growths occur in children under five years of age. The appearance 
of an enlargement in the region of the kidney is, in the majority 
of cases, the first intimation of trouble. A rapidly growing tumour 
of the kidney in a child is a sarcoma or a so-called " mixed " 
tumour. They seldom give rise to urinary symptoms although, 
in a few cases, some hematuria has been noted. Pain is uncommon 
but the tumour may be tender. The child may play about with 
little discomfort until within a few weeks of its death. The tu- 
mour often becomes of large size causing great distention of the 
abdomen. It may be so smooth and soft as to simulate very closely 
a fluctuating mass. When very large, symptoms due to pressure or 
distention may be observed. Eapid emaciation and anaemia are marked, 
51 




Fig. 318. — " Hypernephromata." — Herzog. 



S6 



A TEXT-BOOK OF GYNECOLOGY 



01 



/ *> * 2 /ft 










Fig. 319. — "The tumour cells are . . . found in an 
arrangement very much similar to that seen 
in the zona fasciculata of the adrenal gland." 
— Herzog (page 785). 



and death takes place by exhaustion in from six to eight months 
a year; it is rarely delayed until two years. 

In the adult, hematuria 
is a much more frequent 
symptom of tumour than in 
the child, as it is present in 
malignant tumours in from 
70 to 80 per cent of the cases 
(Guyon). It is spontaneous 
in character, appears at ir- 
regular intervals, is painless, 
and is usually discovered by 
accident. In the majority of 
the cases, a tumour is already 
present when the hematuria 
is first observed, but hema- 
turia may exist for some time 
before any enlargement can 
be felt. Pain can not be said 
to be a characteristic symp- 
tom of renal tumours, but a 
vague, dull ache in the lum- 
bar region has been frequent- 
ly observed. Carcinoma of the pelvis shows a great tendency to 
extend to the ureter. This causes an obstruction to the free escape 
of the urine and leads to the development of a nephrydrosis or 
nephrohematosis. The dura- 
tion of malignant tumours 
in the adult is much longer, 
on the average, than in the 
child, as it is usually from 
two to three or even five 
years before death occurs. 
In tumours of the adrenals, 
hypernephroma, and carci- 
noma, hematuria is rare. 
The kidney may often be dis- 
tinctly felt displaced down- 
ward by the tumour enlarg- 
ing from above. In tumours 
that destroy the adrenals, 
such as the carcinomata, 
marked loss of strength, 
physical depression, and lan- 
guor, are quite characteristic 

symptoms (Eamsay). Some bronzing of the skin has been observed 
a few times but does not appear to be the rule. There are no char- 




Fig. 320.—" The cells show a universal tendency to 
undergo fatty degeneration."— Herzog (page 785). 



THE FEMALE URINARY APPARATUS 787 

acteristic symptoms by which the rather rare benign tumours can be 
distinguished. 

The treatment of tumours of the kidney is removal by nephrectomy. 
Unfortunately, the onset of the malignant tumours is so insidious 
that considerable progress has usually already been made when a diag- 
nosis is established. The remote results in the sarcomata of early 
childhood are not very encouraging, as very few cases indeed are on 
record which have survived the operation for three years. Owing to 
the slower course of these growths in the adult, the remote results are 
better. Wagner has collected 24 cases surviving the operation for more 
than two years. The immediate mortality of nephrectomy for carci- 
noma is 24 per cent (Heresco). Partial nephrectomy has been per- 
formed a few times for supposed benign growths, usually with recur- 
rence. As it is so difficult to determine whether a tumour is benign or 
malignant, the advisability of partial nephrectomy is questionable. 

Operations on the Kidney. — There are three principal operations 
performed on the kidney, namely: 1. Nephropexy (nephrorrhaphy) or 
fixation of a movable kidney. 2. Nephrotomy, the cutting into a kid- 
ney, including pyelotomy, the cutting into the pelvis of the kidney 
for exploratory purposes, for the removal of stone (nephrolithotomy) 
or for the establishment of drainage (nephrostomy). 3. Nephrec- 
tomy, partial (resection), and complete. There are two routes by which 
the kidney may be reached — the anterior, or transperitoneal; and the 
posterior, or lumbar. The advantages claimed for the transperitoneal 
route are : That it permits palpation of the opposite kidney and affords 
easier access to the pedicle in nephrectomy for large tumours. These 
advantages, however, have been overestimated. Palpation of the kid- 
ney gives little knowledge beyond the mere fact of its existence, which 
fact can now be learned by other means; and the pedicle can usually be 
just as easily reached from behind as from the front. On the other hand, 
the danger of infection, the difficulty of closing the peritoneum pos- 
teriorly, and the necessity of providing lumbar drainage, have led 
surgeons to abandon the transperitoneal route except perhaps in rare 
cases of misplaced or displaced and abnormally fixed kidneys. A num- 
ber of incisions have been proposed for reaching the kidney through 
the lumbar region, as the longitudinal, oblique, rectangular, and 
transverse. The distance from the twelfth rib to the crest of the ilium 
is so short that the longitudinal incision seldom affords sufficient work- 
ing space. The rectangular, or Konig's incision, starting from the tip 
of the twelfth rib and extending obliquely downward toward the an- 
terior superior spine of the ilium, then suddenly curving forward and 
upward, and the transverse incision just below the twelfth rib, are 
chiefly employed for the removal of large tumours; while the oblique 
incision, extending from just below and posterior to the tip of the 
twelfth rib, downward and forward, is the one usually employed in 
nephropexy, nephrotomy, etc. If the oblique incision is started a 
little in front of the tip of the twelfth rib, and is extended downward in 



_ 



788 A TEXT-BOOK OF GYNECOLOGY 

the direction of the fibres of the external oblique, it can be made a 
muscle-splitting incision, the fibres of the external oblique being sepa- 
rated longitudinally, and those of the internal oblique transversely, 
to the cutaneous incision. The kidney can, in this manner, be reached 
without dividing muscular fibres, thus minimizing the danger of ven- 
tral hernia. The muscle-splitting incision will be found preferable in 
the majority of operations on the kidney. 

Nephropexy or Nephrorrhaphy. — The kidney having been exposed 
by the muscle-splitting incision, all the perirenal fat should be care- 
fully removed. In doing this the prerenal fascia should be preserved. 
Two flaps of the transversalis fascia, about 5 to 6 centimetres in 
length, are now turned back from 2 to 3 centimetres, one on either 
side of the incision. The anterior flap should be stitched with cat- 
gut to the prerenal fascia and to the anterior surface of the kidney, 
and the posterior flap in a similar manner to the posterior surface of 
the kidney. We thus have the kidney firmly fixed to the posterior 
abdominal wall by two flaps of fascia. The flaps should be made as high 
up as possible, and fixed to the kidney in such a manner that the pelvis 
and ureter shall have a proper direction and the upper portion of the 
latter be free from kink or twist that might offer obstruction to the 
free escape of the urine. That portion of the kidney between the 
attached flaps will lie in contact with denuded muscle when the wound 
is closed. The capsula fibrosa may be scarified to excite a freer pro- 
liferation of connective tissue. If thought desirable, the kidney may be 
transfixed by two or more catgut sutures to hold it more firmly in con- 
tact with the denuded muscle, or it may be denuded of its fibrous cap- 
sule. The wound is then closed and the patient kept in the recumbent 
position for three or four weeks, to allow sufficient time for firm adhe- 
sion to take place. It has been recommended by some simply to expose 
the kidney freely, draw it up and pack the wound with gauze until 
granulations are well established, then allow the wound to close. 
Preference, however, must be given to a closed wound with primary 
union. The numerous attempts to fix the kidney to the ribs by a 
variety of sutures have little to commend them. The success of the 
operation, so far as curing the symptoms is concerned, depends, not so 
much upon fixing the kidney as high up as possible, as upon fixing it 
in such a position that its pedicle shall be free and the urine have 
easy and unobstructed escape. 

Nephrotomy. — Expose the kidney by the muscle-splitting incision. 
If the operation is one of exploration or for the removal of stone, free 
the organ so that it can be palpated throughout, pelvis included. It 
should be opened along its posterior border. The incision, which may 
be made with an ordinary scalpel, should extend into the pelvis and 
may be as long as deemed necessary. As hemorrhage is likely to be 
profuse, the kidney should never be incised unless under perfect con- 
trol of the operator. The organ should be grasped in the hand and the 
incision made between the thumb and fingers. In this manner, pres- 



THE FEMALE URINARY APPARATUS 789 

sure, which readily controls the hemorrhage, is easily applied, and is 
much to be preferred to clamping the pedicle with forceps. The in- 
terior of the pelvis may now be explored, and calculi, if present, re- 
moved. It should then be freely irrigated with hot normal salt solu- 
tion to check oozing and free it of blood clots or debris which might 
form nuclei for new stone formations. If not septic, the kidney should 
be closed by deep and superficial catgut sutures and the external wound 
closed as usual. When the object of the nephrotomy is drainage of 
a suppurating organ, the abscess cavity is opened, cleansed by irriga- 
tion, a good-sized rubber drainage tube inserted, and the wound packed 
with gauze. 

Nephrectomy. — The oblique muscle-splitting incision is suitable for 
kidneys of moderate size. In very large tumours, Konig's, or the trans- 
verse incision, which is particularly applicable in children, will give 
more room. In malignant tumours, it is advisable to remove as much 
as possible of the fatty capsule with the kidney. In nonmalignant 
cases, the kidney is loosened from its surrounding tissue until the 
pedicle is reached, when, if accessible, the vessels and ureter should be 
separately ligated with catgut. Should the presence of the kidney 
interfere with the ligation of the pedicle, an angular clamp may be 
placed on the vessels and the kidney removed. Should it still be found 
impossible to ligate the vessels satisfactorily, the clamp may be left 
in position for about twenty-four hours, when it may be removed with 
safety. In septic cases, the upper end of the ureter should be fixed 
into the lower angle of the wound. When there is considerable peri- 
nephritis fibrosa, as is common in tuberculosis and other chronic septic 
conditions, it may be very difficult, or even impossible, to separate the 
mass from the surrounding organs without great danger of injury, par- 
ticularly to the colon and vena cava. Harris has seen the colon so in- 
jured in this manner as to lead to the formation of a fascal fistula. In 
attempting to separate the inner layer of the mesocolon, there is 
also danger of clamping or ligating one of the colic arteries, which may 
produce sloughing of a portion of the colon. In these cases of peri- 
nephritis fibrosa, it is better to cut directly through to the kidney tissue 
itself, and to enucleate the kidney from its fibrous capsule. The pedicle 
may be so involved in the fibrous mass as to render ligation impossible. 
It will, therefore, be necessary to apply a clamp and allow it to remain 
for twenty-four hours. The wound should be packed with gauze and 
the clamp protected by the dressings. If tuberculous deposits are found 
in the ureter, this canal should be dissected out as far down as possible 
or until all the diseased tissue has been removed. In all operations 
on the kidney, and particularly after nephrectomy, the danger of de- 
ficient elimination by the opposite kidney should always be borne in 
mind. It is necessary, therefore, to supply these patients with an 
abundance of fluid, either by filling the colon with normal salt solution 
or by injecting it subcutaneously. 



CHAPTER XLIX 

THE FEMALE URINARY APPARATUS (Continued) 

Cystitis : Etiology, bacteriology, pathologic changes, symptomatology and diag- 
nosis, treatment — Hyperemia, treatment — Foreign bodies in the bladder, 
treatment — Tumors of the bladder: Symptomatology and diagnosis, treat- 
ment — Urethral caruncle, treatment — Carcinoma of the urethra, treatment — 
Sarcoma of the urethra — Diverticula of the urethra, treatment — Strictures of 
the urethra — Prolapse of the urethra, treatment — Foreign bodies in the 
urethra — Dilatation of the urethra, treatment — The urachus — Vesico-umbilical 
fistula, treatment — Cysts of the urachus. 

Cystitis is an inflammatory condition due to the invasion of the 
walls of the bladder by pathogenic microbes. The urine frequently 
contains microbes but this is not in itself sufficient to produce a cystitis. 
It is absolutely necessary that the microbes should lodge and develop 
either upon or within the walls of this organ, before an inflammatory 
condition can be established. The etiology, therefore, of cystitis may 
be considered under two heads: 1. Those influences that predispose to 
the lodgment and development of the microbes; and 2. The manner 
in which the microbes gain entrance to the bladder. One of the most 
frequent predisposing causes of infection is congestion. This greatly 
reduces the resisting power of the bladder and may be induced in a 
variety of ways. Common among these may be mentioned exposure to 
cold; overdistention of the bladder from prolonged retention of the 
urine; obstruction to the free escape of the urine due to stricture of 
the urethra; intravesical or urethral tumours; displacement of the 
bladder from extra-vesical tumours, uterine displacements, cystocele, 
etc.; traumata, such as contusion of the bladder or prolonged pressure 
from the child's head during labour; contusion from external violence 
or accidental or unavoidable injury by the surgeon during operations 
on neighbouring parts; internal trauma produced by foreign bodies, 
either developed within (vesical calculi), or introduced by the patient 
from without (hairpins, pieces of pencils, chewing gum, etc.), or by 
the physician or nurse (catheter, sound, cystoscope, etc.); abnormal 
states of the urine due to the elimination of irritating substances intro- 
duced from without (cantharides, turpentine, oil of sabine, etc.), or 
developed within the body (toxines from intestinal disturbances, acute 
infectious diseases, etc.). The bladder participates somewhat in the 
general congestion of the pelvic organs accompanying menstruation, 
790 



THE FEMALE URINARY APPARATUS 791 

and this congestion may be greatly increased by sudden suppression 
of this function. 

The second essential factor in the production of the inflammation, 
namely, the pathogenic microbes, may gain entrance to the bladder: 
1. Through the urethra; 2. From the kidneys with the urine; 3. From 
contiguous parts; 4. From the blood. The most common route is un- 
doubtedly along the urethra. The shortness of this canal in women 
makes it much easier for microbes to enter the bladder through it in 
them than in men. Gonorrhceal infection, which always affects the 
urethra, may extend to the bladder. Infections from other microbes 
involving the vulva, vestibule, or vulvo-vaginal glands, may likewise 
extend along the urethra. The germs may be carried to the bladder on 
septic catheters or other instruments. Even a sterilized catheter may 
carry germs that are within or about the meatus into the bladder. 
The bruised and congested condition of the bladder following con- 
finement or operations on the generative organs, makes the introduction 
of germs by the catheter particularly liable to excite a cystitis. The 
greatest care should, therefore, always be taken in cleansing the meatus 
and adjoining parts, and in sterilizing and introducing the catheter 
under these conditions. The patient herself may introduce the germs 
on all sorts of foreign bodies used for masturbating purposes or when 
mentally deranged. Germs frequently reach the bladder by descending 
with the urine from the kidneys. It is not necessary that the kidneys 
be diseased, as it is well known that these organs frequently eliminate 
microbes from the blood without themselves being involved thereby. 
This may take place in the acute infectious diseases, in diseases of the 
intestinal tract, and in suppurative conditions in other portions of the 
body. The kidneys, however, may be the primary point of infection, 
as in pyelitis, nephropyelitis, etc., and this is particularly common in 
tuberculous infection. The transmission of microbes to the bladder by 
contiguity may occur in intrapelvic suppurative conditions such as 
pyosalpinx, circumscribed suppurative peritonitis, infections of the 
uterus, etc. Such purulent collections may rupture into the bladder, 
thus carrying infection directly. Infection may come from the rectum, 
from a loop of inflamed bowel that has become adherent to the bladder, 
or even from the appendix, as Harris has seen in one case. The intro- 
duction of germs by direct trauma, as in bullet wounds, punctured 
wounds, etc., is possible but not common. Lastly may be mentioned 
pure hematogenous infections, where germs reach the bladder wall 
through the blood, as either minute septic emboli or floating germs. 
The normal bladder possesses considerable immunity to infection. 
Therefore, in addition to the germs, which are the essential element of 
inflammation, certain of the above-mentioned predisposing conditions 
must be present to temporarily reduce the resisting power of the tissues 
in order that the germs may lodge and develop and cystitis be produced. 

Bacteriology. — To the investigations of Bumm, Clado. Halle and 
Albarran, Krogius, Escherich, Posner, Lewin, Melchoir, Eovsing and 



792 A TEXT-BOOK OF GYNECOLOGY 

others, is due our knowledge of the bacteriology of cystitis. Many 
varieties of bacteria have been found in the bladder. The one most 
frequently present is the colon bacillus. It reaches the bladder, usually, 
from the kidneys with the urine, but may pass directly from the bowel 
to the bladder when these two organs are connected by inflammatory 
exudate or adhesions. It may also enter through the urethra. This is 
most common in very young girls, where, in the presence of acute 
intestinal disturbances, from lack of cleanliness, a vulvar inflammation 
develops and the infection extends along the urethra to the bladder. 
As the colon bacillus does not decompose urea, the urine remains acid 
in colon cystitis. The gonococcus almost always enters the bladder 
through the urethra. This may occur during an acute gonorrhoea or 
during one of the frequent slight exacerbations of a chronic or latent 
infection. Many of the cases of cystitis following childbirth originate 
in the latter manner, favoured by the bruised condition of the bladder 
and urethra incident to the labour. The gonococcus, likewise, does not 
decompose urea. Of the ordinary pyogenic microbes, the streptococci 
are more frequently found than the staphylococci. They may reach 
the bladder on unsterilized instruments or from contiguous suppurat- 
ing foci, and are frequently found associated with tumours of the 
bladder, as the epitheliomata, papillomata, etc. The streptococci do 
not decompose urea but almost all the staphylococci do. Therefore, in 
the presence of the latter, we find ammoniacal alkaline urine. The 
proteus of Hauser has been found a number of times in cystitis. It acts 
very energetically on urea and the urine is therefore strongly ammoni- 
acal. The prognosis in infection by the proteus of Hauser is unfavour- 
able, as 3 out of 4 subjects seen by Melchoir died. Krogius saw 2 sub- 
jects, both of whom died. The tubercle bacillus is a common cause of 
chronic cystitis and usually infects the bladder from a tuberculous focus 
in the kidney. The urine in tuberculous cystitis remains acid. Other 
bacteria have occasionally been found in cystitis, but not with suf- 
ficient frequency to demand special mention. Mixed infections may 
likewise occur. 

The pathologic changes produced are much the same regardless of 
the particular kind of microbe present, with the exception of the 
tubercle bacillus which alone produces somewhat characteristic 
changes. Marked differences, however, exist in degree. The same 
variety of microbe may at one time produce the most extensive changes, 
and at another time almost none, for reasons that can not better be ex- 
pressed than by the terms, " varying virulence " on the part of the 
microbes, and " power of resistance " on the part of the bladder. The 
changes produced are hyperemia with swelling and infiltration. These 
may be circumscribed or diffuse. In the former case, they may be limited 
to a small area about the inner orifice of the urethra, to the trigone, or 
to a small area about one or the other ureteral orifice. In severe cases, 
the mucosa is considerably swollen and thrown into folds. It is soft, 
often oedematous, and small hemorrhages are not infrequent. Erosions 



THE FEMALE URINARY APPARATUS 793 

may occur, particularly on the folds. Papillomatous elevations which 
are soft and bleed easily on touch may form. Inflamed areas may 
become covered by a grayish or yellowish membranelike substance 
composed of pus cells, mucus, bacteria, detached epithelial cells, etc., 
in which phosphates may be deposited, and which may adhere quite 
intimately to the mucosa. The changes may extend to the submucosa 
and muscularis, where abscesses may form that may rupture into the 
bladder or into the pericystic tissues. The inflammatory changes may 
extend through the entire wall of the bladder producing a pericystitis. 
In chronic cases the muscularis becomes greatly hypertrophied, the 
walls much thickened, and the capacity of the organ markedly reduced. 
In a particularly virulent infection following childbirth or some of 
the acute infectious diseases, the mucosa may slough. A diphtheritic 
cystitis may likewise occur. In tuberculous cystitis the changes are 
usually circumscribed and appear first about the ureteral orifices. 
Small, slightly elevated tubercles, ma}' be seen, which undergo casea- 
tion and softening, and break down forming small ulcers. There may 
be but a single ulcer or they may be multiple. When a mixed infec- 
tion is present, the usual changes may be seen in addition to the 
ulcers. 

Symptomatology and Diagnosis. — Cystitis manifests itself by pain- 
ful, frequent urination, and changes in the character of the urine. 
The severity of the symptoms varies greatly. In acute cystitis, the 
desire to urinate is very urgent and the pain accompanying the act quite 
marked. The increased sensitiveness of the mucosa impels the patient 
to evacuate the bladder so soon as a small amount of urine accumulates 
within it, and the contraction of the muscle incident thereto is the 
chief cause of the pain. In severe cases it is necessary to urinate 
frequently, sometimes as often as every few minutes, day and night; 
and as the relief obtained is often slight or of short duration, the 
patient is almost constantly tormented and thus deprived of much 
needed rest and sleep. In milder cases, urination may be necessary 
only every hour or two during the day and two or three times at night. 
The pain is felt deep in the lower part of the abdomen or behind 
the symphysis pubis. It is often of a burning or smarting character, 
and may extend along the urethra to the meatus. Changes in the 
character of the urine are always present. The old idea that cystitis 
was always associated with ammoniacal urine is an error. The reaction 
depends upon the kind of infection present, and we may have a severe 
cystitis with a constantly acid urine, as shown under Bacteriology. 

When the cystitis is due to a urea-decomposing microbe, the urine 
is alkaline, ammoniacal, and irritating, and contains the usual triple 
phosphate crystals. More or less pus is always present. It may vary 
from microscopical quantities to sufficient to produce a slight turbidity 
of the urine, or to from 10 to 25 per cent by bulk upon sedimentation. 
The urine contains an increased amount of mucus. Xumerous squa- 
mous and transitional epithelial cells from the bladder mucosa are always 



794 A TEXT-BOOK OF GYNECOLOGY 

found on microscopic examination, and a few blood cells are com- 
mon. In acute cases, a drop or two of blood is often squeezed out 
at the end of urination by the spasmodic action of the bladder. In 
so-called gangrenous or sloughing cystitis, shreds of mucous membrane 
may be passed. The ordinary case of cystitis is unattended by any 
material elevation of the temperature, but in case of abscess formation 
in the wall of the bladder, of pericystitis, or of extension of the infec- 
tion to the kidneys, fever may become a prominent symptom. The only 
difference between acute and chronic cystitis is simply one of time, as 
the symptoms and causation may be the same in each. The acute form 
frequently passes imperceptibly into the chronic, and chronic cases 
are subject to repeated acute exacerbations. Acute cystitis may be ex- 
pected to subside under proper care in from a few days to two or three 
weeks, while the chronic form may persist with varying intensity for 
months or years. The great danger in cystitis is the extension of the 
infection to the kidneys. More remote is the possibility of perforation 
of the bladder with infection of the peritoneum or the formation of 
pericystic abscesses. As similar symptoms and changes in the character 
of the urine may occur in diseases of other portions of the urinary 
tract, the diagnosis of cystitis must rest upon a demonstration of the 
lesions of the vesical mucosa or upon establishing the fact that the 
pathologic elements found in the urine have their origin within the 
bladder. These facts are determined by palpation of the bladder, by 
the use of the cystoscope, and by segregation of the urines. Upon 
bimanual palpation, the bladder will be found to be sensitive if in- 
flamed; and if the inflammation has been of long duration, the in- 
creased thickness of the walls can be easily felt. By the use of the 
cystoscope, either the Kelly tube or the electro-cystoscopes, the various 
alterations already described under Pathologic Changes may be easily 
recognised and an absolute diagnosis made. By ureteral catheterization 
or the use of the urine segregator, the condition of the kidneys, as 
separate from the bladder, may be determined, but the danger of 
infecting a healthy kidney with the ureteral catheter in the presence 
of a septic bladder should always be remembered. The diagnosis is not 
complete without a bacteriological examination to determine the nature 
of the infection. The general health in mild cases may be but little 
affected, but in severe cases the prolonged, almost continuous suffering 
often greatly reduces the patient. 

Treatment. — As the bladder possesses considerable reparative power 
provided the predisposing factors mentioned under Etiology are re- 
moved, each case of cystitis should be diligently studied in order to 
discover and abate, if possible, all such factors as favour infection or 
diminish the resisting power of the bladder. Attention should thus 
be directed to infections about the vagina, vulva and urethra; to stric- 
tures of the urethra, or other causes of obstruction to the free escape 
of urine; to intrapelvic infections or tumours that press upon or dis- 
tort the bladder; to intestinal diseases that may permit direct or indirect 



THE FEMALE URINARY APPARATUS Y95 

infection of the bladder; to septic foci in the kidneys producing de- 
scending infection; to abnormal, irritating conditions of the urine, 
and to foreign bodies or tumours in the bladder, etc. Having relieved 
these conditions, so far as possible, attention may be directed to the 
bladder itself. In acute cases, the patient should be confined to bed. 
An abundance of water should be given to dilute the urine, and potas- 
sium carbonate, citrate, or acetate, to reduce its acidity. The food 
should be very light and mostly of a liquid character. Hot applica- 
tions to the hypogastric region and vulva afford some relief to the 
pain, as do also hot sitz baths, and hot vaginal douches. The pain 
and burning during urination may be ameliorated by having the patient 
urinate in the sitz bath or while taking a vaginal douche. In severe 
cases, morphine or codeine may be necessary to relieve the pain. An 
excellent combination is salol, 3 grains, with codeine, -J to J of a 
grain, every two or four hours. In the early stages of very severe acute 
cases, vesical instrumentation should be avoided; but after the most 
acute stage has subsided, or in milder cases from the beginning, a vesical 
douche of warm 2-per-cent boric-acid solution gently and carefully 
given will be found of great service. In chronic cases, the bladder 
should be cleansed by irrigation daily with warm boric-acid solution, or 
formalin 1 to 2,000 or 3,000 in normal salt solution; mercuric bichlo- 
ride, 1 to 10,000 or 20,000, or silver nitrate 1 to 1,000 or 2,000. In 
all cases, the interior of the bladder should be inspected, and where 
the changes are found to be circumscribed, direct application of a 
2-per-cent to 3-per-cent solution of silver nitrate should be made to the 
diseased areas. In tuberculous cystitis with ulceration, the ulcers may 
be curetted and from 2 to 4 drachms (8 to 15 cubic centi- 
metres) of iodoform emulsion (10 per cent) allowed to remain in the 
bladder. Internally, such remedies may be given as have been found 
to exert an inhibitory action on the growth of the microbes while 
being eliminated with the urine. Of these, salol and urotropin are the 
best, the former in doses of 5 grains (0.3) four to six times a day, and 
the latter of from V to 10 grains (0.5 to 0.7) three times daily. The diet 
should be regulated, and all irritating articles of food and alcoholic 
drinks interdicted. 

Should the above means fail to give relief, complete rest to the 
bladder should be secured by continuous drainage either by the catheter 
a demeure or by suprapubic cystotomy. 

Hyperemia. — Under the terms hyperemia, irritable bladder, neu- 
ralgia of the bladder, etc., has been described a condition which is 
quite common in women, and often very troublesome. While it is 
possible that a neuralgia of the bladder may occur, the term is entirely 
unsuited to the condition at present under discussion. Of the other 
two terms mentioned, hyperemia seems the more appropriate, 
although it is quite impossible to draw a sharp distinguishing line 
between a simple hyperemia and a mild cystitis. If the cases of so- 
called " irritable bladder " are examined with the cystoscope and the 



790 A TEXT-BOOK OF GYNECOLOGY 

endoscope, changes quite typical of a mild inflammation will be ob- 
served in a large majority of them. These changes are usually quite 
circumscribed in outline. They may be limited to the trigone (trigo- 
nitis) or to a small area about one or the other ureteral opening. 
Most frequently, the vesico-urethral junction, or that portion which 
first begins to fold over the end of the endoscope as it is withdrawn 
from the bladder, will be found involved. These areas are quite red, 
often swollen or slightly cedematous, very sensitive when touched with 
the end of a probe or applicator, and, at times, they bleed easily, par- 
ticularly the above-mentioned vesico-urethral junction. Many of 
these cases are undoubtedly due to a mild infection, and the question 
of infection is the only distinguishing point between a simple hyper- 
emia and a beginning true inflammation. Women with chronic uter- 
ine displacements are common sufferers in this way, and Harris has 
seen a number of cases in spinster seamstresses who use the sewing 
machine to excess, and in women with movable kidneys. A neurotic 
element is often strongly marked, and many times the vesical symp- 
toms are but a part of a general neurasthenia. The symptoms are a 
frequent desire to urinate, with a burning or smarting sensation ac- 
companying or following the act. The discomfort often becomes quite 
distressing. Eemissions, or even intermissions, in the symptoms are 
quite common. The treatment must be governed by the etiologic condi- 
tions present. Uterine complications must be corrected; and concen- 
trated and irritating urine must be diluted and modified by giving 
plenty of pure water and such diuretics as potassium citrate, with triti- 
cum repens or stigmata maidis. Codeine may be added if the pain is 
severe. The neurotic element, when present, must be duly considered 
and treated with proper diet, tonics, exercise, etc. The local treatment 
consists in irrigations with warm boric-acid solution, 2 per cent, or the 
direct application through the cystoscope of a 2-per-cent to 4-per-cent 
solution of silver nitrate to the hyperaemic patches. In many cases, 
particularly in those associated with a nervous element, dilatation of 
the urethra is followed by marked improvement. 

Foreign Bodies in the Bladder. — By the term foreign bodies is 
meant, not only such articles as are wilfully or accidentally introduced 
from without, but also such as originate within the bladder. Under 
the latter division are to be considered vesical calculi. These, as pri- 
mary formations, are very rare in the female. Most primary bladder 
stones have their origin in small calculi that descend from the kidneys 
and, failing to escape from the bladder, gradually enlarge by the fur- 
ther deposit about them of the urine salts. The rarity of such stones 
in the female is due to the short, dilatable urethra which readily per- 
mits the escape of any concretion that may enter the bladder through 
the ureters. Whenever, therefore, a primary stone is found in the 
female bladder, it is usual to find some antecedent condition present 
which interferes with the prompt and complete evacuation of the 
urine. Among such conditions may be mentioned strictures of the ure- 



THE FEMALE URINARY APPARATUS 797 

thra, either from cicatricial contraction or pressure from without; tu- 
mours within the bladder which interrupt the escape of the urine; 
pouching of the bladder, such as occurs in diverticula and cystocele; 
distortions or displacements of the bladder from intrapelvic tumours; 
adhesions of this organ to neighbouring parts, which interfere with 
its free contraction, etc. In the presence of any of these conditions, 
a concretion descending from the kidney may remain in the bladder 
and develop to a stone of considerable dimensions. As such stones 
are identical in origin and structure with those that develop within 
the kidneys, the reader is referred to the article on Eenal Calculi for 
their etiology and composition. By far the large majority of vesical 
calculi in the female are not of the so-called primary variety, but 
develop as secondary formations about foreign bodies that have been 
introduced from without. Most of such bodies enter the bladder 
through the urethra, but other routes are possible; a pessary, for 
instance, may ulcerate from the vagina into the bladder; ligatures 
placed in the bladder wall, or even about pedicles in the pelvis, may 
find their way into the bladder; particles may enter from the ali- 
mentary canal in vesicointestinal fistula?; pieces of bone, clothing, 
etc., may be carried to the bladder by bullet wounds, etc. As already 
stated, however, the urethra is the most common route, and of 391 
cases of foreign bodies in the bladder collected by Denuce, 258 were 
introduced intentionally, that is, out of morbid curiosity or for mas- 
turbating purposes. Among the various articles thus introduced, 
may be mentioned hairpins, glass-headed pins, beads, pieces of lead 
pencils, slate pencils, chewing gum, straws, small paraffin candles, 
peas, kernels of corn, etc. Foreign bodies may likewise find their 
way into the bladder accidentally, as when the end of a catheter breaks 
off or a whole glass catheter slips in, as mentioned by Kelly, or a 
lithotrite or other instrument breaks while being manipulated within 
the organ. A foreign body may remain in the bladder a long time 
without inducing any special symptoms. Thus, Letulle mentions a 
case in which a penholder, 8 centimetres long, remained in the blad- 
der three months without producing the slightest trouble, and Stein- 
itz, one where a broken-off rubber catheter remained seventeen years 
without giving rise to any considerable difficulty. Usually, however, 
severe symptoms very soon arise. Painful contractions of the bladder 
may be induced, particularly if the body has sharp points, and per- 
foration of the organ may occur with the development of a fatal peri- 
tonitis. Ordinarily, the symptoms are those of a simple cystitis ; pain- 
ful, frequent urination, with blood, pus, and decomposition of the 
urine. The decomposition of the urine leads to the deposition of 
phosphates about the foreign body as a nucleus, and thus are devel- 
oped secondary stones. While the pain is usually more severe after 
emptying the bladder or following exercise or jolting of the body, 
and while the amount of blood present in the urine is usually more 
pronounced than in ordinary cases of cystitis, still the symptoms are 



798 A TEXT-BOOK OF GYNECOLOGY 

not absolutely characteristic of the presence of a foreign body, which 
fact must be demonstrated by bimanual palpation, the introduction 
of the sound, or inspection through the cystoscope. 

The treatment consists in the removal of the foreign body, whatever 
it may be. A primary stone, if not too large, may be removed through 
the dilated urethra, or it may be crushed with the lithotrite and 
washed out with the evacuator. Much ingenuity must often be dis- 
played in the removal of irregular bodies or those with sharp points. 
Much, however, may be done through the dilated urethra with the 
cystoscope and forceps, while the patient is in the knee-chest position 
and the bladder distended with air. In dilating the urethra, the ex- 
ternal meatus should be incised laterally and in the middle line, and 
the dilatation, which should be made slowly with smooth dilators, 
should not exceed 18 to 20 millimetres, owing to the danger of pro- 
ducing permanent incontinence. The incisions of the meatus should 
subsequently be sutured. When the body can not be removed through 
the dilated urethra, it will be necessary to incise the bladder either 
from the vagina or above the pubis. The suprapubic route is usually 
to be preferred, as it affords easy access to the bladder and there is 
no danger of injuring the ureters or of leaving a permanent vesico- 
vaginal fistula. By distending the bladder with air, the peritoneal 
fold is well raised up and the organ may be opened without difficulty. 
The incision in the bladder should be closed with catgut stitches 
which should not enter the vesical cavity, and a catheter a demeure 
introduced. 

Tumours of the Bladder. — As both the entoderm and the meso- 
derm enter into the formation of the bladder, nearly all varieties of 
tumours have been found taking origin from its walls. The benign, 
mature connective-tissue tumours, fibromata, myomata, and lipomata, 
are very rare, and but few well-marked specimens have been recorded. 
They have their origin in the submucous and muscular layers. 

The malignant embryonal connective-tissue tumours, myxomata 
and sarcomata, although more common than the benign growths, are 
still to be classed with the rarer forms. Of the epithelial growths, 
the carcinomata are much the more frequent, only a few adenomata 
having been observed. By far the most common tumour found in the 
bladder is the so-called papilloma or villous growth. 

The typical villous growth is made up of a number of delicate, 
slender prolongations which subdivide or branch similarly to an ordi- 
nary shrub. Each little prolongation is composed of a central blood- 
vessel loop, surrounded by a variable amount of loose connective tissue, 
and the whole covered by several layers of epithelial cells of the vesicle 
type. While this is the general character of a villous growth, varia- 
tions may exist in the length and size of the prolongations, number 
of branches, extent of attachment at the base, amount of connective 
tissue present, number of layers of epithelial cells on the surface, etc. 
In size, they may vary from a few millimetres in height and circum- 



THE FEMALE URINARY APPARATUS 799 

ference to several centimetres. Much confusion exists in the litera- 
ture from an attempt to name and classify the papillomata. 

A papilloma ma}' exist for years without leading to the destruc- 
tion of tissue or the patient; it may be removed without displaying 
the slightest tendency to recur, thus exhibiting every evidence of a 
benign growth. On the other hand, infiltration and destruction of the 
bladder walls may result, metastases may form, and rapid recurrence 
after removal, and death within a short time, may take place, thus 
exhibiting every evidence of great malignancy. The papillomata 
may, therefore, be classified as simple, or benign, and carcinomatous, 
or malignant. The benign growths are usually pedunculated, with 
narrow bases and without infiltration. The malignant are more ses- 
sile, with broad bases and infiltration of the bladder walls. Typical 
exemplars of these two varieties would perhaps be easily recognised, 
but unfortunately many atypical cases are found. Cases which show 
no infiltration macroscopically, ma}' show, upon microscopic examina- 
tion of serial sections through the base, beginning epithelial inclusions 
and prolongations from the surface layers. These cases, after re- 
moval, show a tendency to recur as typical infiltrating carcinomata. 
The occurrence of such cases makes it impossible always to determine, 
from gross appearance alone, whether a papilloma is benign or malig- 
nant. It is, therefore, safer to look upon them all with suspicion and 
to treat them as if they were malignant. Tumours of the bladder 
may appear at any time of life from infancy to old age. The large 
majority of tumours in early life are malignant. Steinmetz 
(Deutsche Zeitschrift fur Cliirurgie, Bd. xxxix, s. 313) collected 32 cases 
in childhood. There were 14 sarcomata; 13 myxomata; 1 fibromy- 
oma; 1 cystofibroma; 1 rhabdomyoma; and 2 of a nature not stated. 
The clinical history of the myxomata differed in no way from that 
of the sarcomata. Concerning the age, there were 23 between one and 
five years, and only 6 from five to thirteen years. During adolescence 
and early adult life, tumours of the bladder are very rare; after thirty 
they again increase in frequency, and are most common from forty to 
sixty. 

Symptomatology and Diagnosis. — In adults, the first symptom is 
usually hematuria. This is of the so-called spontaneous variety; 
appearing and disappearing without apparent cause, and usually unin- 
fluenced by exercise or exertion. It may last but a short time or per- 
sist for months or years, and may be slight or quite severe. For a 
time, there may be no subjective symptoms present; sooner or later, 
however, increased frequency of urination and pain are noted. These 
are more marked and appear earlier when the growth occupies the 
base of the bladder or the region near the internal orifice of the 
urethra. A pedunculated growth in this region may enter the urethra 
and make its appearance at the meatus urinarius. This has been 
particularly noted in children, and has frequently been the first symp- 
tom directing attention to the bladder. When the bladder becomes 



800 A TEXT-BOOK OF GYNECOLOGY 

infected, as it is particular!)' prone to do in malignant cases, the 
symptoms are those of an ordinary cystitis. In about 25 per cent of 
malignant cases, the earlier symptoms are those of a simple cystitis. 
It is impossible to distinguish between a benign and a malignant 
growth by the symptoms in the early stage, but later, the cachexia, 
loss of flesh, failure of general health, etc., stamp the case as ma- 
lignant. 

Direct inspection of the interior of the bladder through the cysto- 
scope is the only means of making a positive early diagnosis of blad- 
der tumour. By the use of this instrument, the extent and the gen- 
eral physical characteristics of the growth may be observed. An infil- 
trating, ulcerating growth is almost certainly malignant, but in the 
case of a papilloma it will be difficult to decide, and it is better to 
await the findings of the microscope before expressing a positive 
opinion. The duration of a benign growth is often one of years, but 
a malignant tumour is usually fatal in from one to three years. 

Treatment. — All tumours of the bladder should be removed as soon 
as possible. Pedunculated growths may often be removed through 
the dilated urethra with the snare or galvano-caustic loop, but in the 
majority of cases the suprapubic route will be found the most satis- 
factory, as it permits free access to all parts of the bladder and a 
more thorough removal of the growth. Even in cases that appear 
benign, it is safer to remove the base freely, as if it were malignant. 
In infiltrating malignant growths a resection of the bladder walls 
should be made. This is not so difficult when the mass occupies the 
fundus, but when the base is involved, or the region about the ureters, 
it becomes a very serious and difficult operation. The ureters must 
be transplanted higher up in the posterior wall or fundus. When the 
organ is extensively involved, it may be necessary to remove it com- 
pletely. This has been successfully done, and the case of Pawlik 
may be taken as a model, although the details of each operation will 
have to be worked out by the operator and modified to suit the indi- 
vidual case. Pawlik turned the ureters into the vagina as a prelim- 
inary operation. He then removed the bladder working from above 
and below, but preserved the urethra which he likewise turned into 
the vagina. The vaginal opening was subsequently closed and this 
organ made to supply the place of a bladder. The ultimate result was 
very gratifying. 

Urethral Caruncle. — With the exception of gonorrheal urethritis, 
diseases of the female urethra are rare. The conditions most com- 
monly met with are tumours, diverticula, strictures, prolapse, the pres- 
ence of foreign bodies, and dilatation. Of the tumours, the most com- 
mon is the urethral caruncle. This usually presents itself as a small 
red mass projecting from the orifice of the urethra and attached by 
a narrow pedicle to the mucosa within the meatus. It is often some- 
what flattened laterally owing to pressure between the labia. It is 
composed of connective tissue abundantly supplied with blood vessels 



THE FEMALE URIXARY APPARATUS 801 

and covered with several layers of flattened epithelial cells. These 
little growths are usually exquisitely sensitive. Urination is so pain- 
ful that the act is delayed as long as possible, and, in the married, 
marital relations are often impossible owing to the acute pain pro- 
duced by the gentlest touch. They may occur at any age, but are more 
common later in life. In the presence of such symptoms the diagno- 
sis is easily made by inspection. 

Treatment consists in removal. This may be done under local 
anaesthesia by the application for a few minutes of a 10-per-cent 
solution of cocaine. The little mass should be drawn out and the 
pedicle divided close up to the base. Should the base be quite broad, 
the wound may be closed by stitches. 

Carcinoma of the urethra, as either a primary or a secondary affec- 
tion, is not common. Ehrendorfer (Arcliiv filr Gynakologie, Bd. lviii, 
s. 463) was able to collect 27 cases from the literature including one 
of his own. These cases presented three forms: 1. Warty, papillo- 
matous excrescences, developing from the mucosa and projecting from 
the urethra ; 2. Thick, nodular, infiltrating masses in the periurethral 
tissues, involving more or less of the circumference of the urethra and 
usually located toward the external end. and 3. Ulcerated surfaces 
with thickened, irregular and infiltrated edges. These may begin at 
any point along the canal including the meatus. Enlargement of the 
inguinal lymph glands was recognised and mentioned in only about 
one third of the cases. As is usual with carcinoma, the majority of 
the cases occurred late in life. 

The symptoms first complained of, are usually a sense of itching 
and irritation about the meatus or vulva, due to the irritating, acrid 
discharge commonly present, and pain or smarting on urinating. The 
presence of these symptoms should always lead to an examination, 
when, on inspection, with the aid of the endoscope if necessary, and 
palpation, one of the above-described conditions, should it exist, will 
be recognised and a diagnosis made. 

The treatment is early and thorough removal. The anterior por- 
tion of the urethra may be removed and continence of urine remain. 
Should it be necessary to remove the entire urethra, the bladder may 
be closed below and a suprapubic opening made after the method of 
Witzel. 

Sarcoma of the urethra has been noted, but the clinical history and 
treatment do not differ from that of carcinoma (see Neoplasms of the 
External Organs, Chapter XIX). Of the benign tumours, a few 
cases of fibroma have been described occurring for the most part in 
little girls. They presented as small polypoid masses protruding from 
the urethra and attached by a narrow pedicle. Their removal is a 
simple matter. 

Diverticula usually extend from the posterior wall of the urethra 
toward the vagina. They may vary in size from that of a pea to that 
of a cavity holding several cubic centimetres. According to Eoush, 
52 



802 A TEXT-BOOK OF GYNECOLOGY 

they originate from the rupture of retention cysts, blood cysts, or 
periurethral abscesses into the urethra. The distended pocket pro- 
duces a protrusion, or bulging, of the anterior wall of the vagina, 
easily seen on separating the labia. Upon pressure, the enlargement 
diminishes in size and, at the same time, pus or pus and urine escape 
from the urethra. An examination with the endoscope will reveal a 
small opening in the posterior wall of the urethra from which the pus 
escapes, and through which a probe may be passed into the cavity. 
Owing to the decomposition of the urine, which takes place in the 
cavity, a calculus may form therein. Most of these cases give a his- 
tory of long-continued vesical irritation with frequent, painful urina- 
tion, etc. 

The treatment consists in opening the sac freely from the vagina, 
curetting the walls, or painting with tincture of iodine and packing 
with gauze. Should this not be successful, an attempt may be made 
to dissect out the sac. 

Strictures of the female urethra are quite rare. They are due to 
cicatricial contraction following injury the result of external violence 
or lacerations during labour, and they occasionally follow a virulent 
gonorrheal infection or the healing of a urethral chancre. They 
may be easily recognised with the bougie a boule and should be treated 
by gradual dilatation or division followed by dilatation. 

Prolapse of the urethral mucosa may follow a difficult labour or 
may occur in poorly nourished young girls following straining, cough- 
ing, etc. In a severe urethritis the mucosa may become so swollen 
as to protrude considerably. In some cases it is impossible to assign 
a direct cause for the prolapse. The prolapsed mucosa presents a 
dark red or bluish mass, which is sensitive and bleeds easily, and in 
the centre of which may be found an opening leading into the urethra 
(Fig. 86, Displacements of the Vagina). If allowed to remain long 
protruded, the mass may become so constricted as to produce 
sloughing. 

Treatment. — An attempt should be made to reduce the mass by 
gentle pressure. Permanent reduction has followed the application 
of an ice bag to the parts with the patient in the recumbent position. 
Should these means fail or should sloughing threaten, the mass may 
be removed with the knife or scissors, the edges being carefully 
stitched to prevent hemorrhage and retraction as described under Dis- 
placements of the Vagina. 

Foreign bodies in the urethra arc small calculi that have lodged 
in attempting to pass from the bladder, or that develop in a dilated or 
pouched urethra; or they are small bodies introduced from without 
through the meatus. They give rise to painful and difficult urina- 
tion, and can be felt by the finger pressing along the urethra through 
the anterior wall of the vagina or by introducing a probe or catheter 
into the canal. Calculi are usually of the phosphatic variety. Re- 
moval may be effected through the dilated urethra by means of a 



THE FEMALE URINARY APPARATUS 803 

small forceps or a wire loop. When lodged in a pocket, it may be 
necessary to incise the pouch from the vagina in order to reach the 
stone. 

Dilatation of the urethra may occur from the introduction of large 
bodies from without or the expulsion of calculi or tumours from 
within- Coitus per urethram in women with atresia of the vagina, and 
the introduction of large foreign bodies for masturbating purposes, 
have given rise to extreme dilatation with eversion and gaping of the 
urethral orifice. Severe laceration of the urethra has been produced 
by attempts at coitus. Fritsch is, therefore, of the opinion that at 
least a congenital disposition to dilate is present in those cases of 
extreme dilatation that have occurred without the production of 
symptoms. More or less incontinence of urine is the usual result in 
these cases. Upon the slightest straining, such as coughing, sneezing, 
or making a sudden misstep, urine escapes and soils the patient so 
that the condition becomes very annoying. 

Treatment. — In slight degrees of dilatation, the application of a 
10-per-cent solution of silver nitrate to the interior of the urethra 
lias been followed by benefit. The use of astringent vaginal douches 
and tampons may be tried, or a pessary so constructed as to press on 
the urethra may be worn. When the dilatation is marked, these 
means will seldom be found sufficient. It will then be necessary to 
resort to operative measures. Several procedures have been employed, 
the most reliable of which are: 1. The removal by an elliptical inci- 
sion of a portion of the anterior vaginal wall, extending down to, or 
even including, the wall of the urethra, with closure of the space by 
transverse stitches. 2. Freeing the distal end of the urethra by dis- 
section and carrying it forward or upward toward the clitoris where it 
is brought to the surface through a new opening in the vestibule. 3. 
Gersuny's operation of dissecting the urethra free throughout its 
entire length and twisting it upon its axis from 180 to 360 degrees. 
It is then stitched in this position. 4. Fritsch's operation, which 
consists in removing an elliptical piece from the dorsal surface of the 
urethra at its junction with the bladder through a transverse incision 
between the urethra and the arch of the pubis. The urethra is closed 
with catgut stitches, the wound packed, and the bladder drained by a 
self-retaining catheter. 

The selection of the method of operating will depend somewhat 
upon the severity of the case. Gersuny's and Fritsch's operations are 
suitable for the more marked cases. 

The urachus is a cordlike remnant of fcetal structure extending 
from the fundus of the bladder to the umbilicus. It is a portion of 
the allantoic vesicle, from which were derived the urethra and bladder. 

This rudimentary canal consists of three layers: (a) an inner epi- 
thelial layer; (b) a middle basement membrane, and (c) an outer 
fibrous layer. The epithelial layer consists of a variety of cells, cor- 
responding in form and size to those found in various parts of the 



M 



804 



A TEXT-BOOK OP GYNECOLOGY 



S«i t>' 



urinary apparatus. They are either ovoid or polygonal, and are gen- 
erally nucleated. The intermediate layer of basement membrane is 
described by Lnschka as being structureless, delicate and transparent. 
The outer, or fibrous, layer, while attached to the outer side of the 
basement membrane, is distinctly separated from the surrounding 
cellular tissue. It will be seen, therefore, that while this structure 
exists as a blind, and ordinarily functionless, canal, it possesses all 
the histological elements, to render it a highway of communication. 
Luschka declares that, in the majority of male subjects, this canal is 
found to be partially opened, and goes to the extent of stating that 
it possesses a mucous membrane. Tf this is true, as it may be in 
certain instances, the necessity for its patulousness becomes apparent. 
Vesico-umbilical fistula is occasionally encountered, and is the 
result of the failure of the urachus to become closed at both its vesical 

and umbilical extremities. 
It is generally observed as 
a congenital condition, al- 
though it has been found 
in patients of forty and 
even sixty-six years of 
age. When urine escapes 
from the navel, this con- 
dition may be premised. 
A flexible sound can gen- 
erally be passed without 
difficulty from the navel 
orifice into the bladder. 
The bladder in such cases 
can be catheterized by this 
route. While in the ma- 
jority of cases this condi- 
tion is congenital, there 
are instances on record in 
which an opening has 
been forced through the 
urachus, by retention of 
urine. Atresia of the ure- 
thra, clue to gonorrhoea, 
prostatic enlargement, 
and phimosis, has been 
recorded as a direct ex- 
citing cause of vesico-um- 
bilical fistula. The treat- 
ment consists in removing the urachus by abdominal section. A median 
incision should be made from the umbilicus to near the pubis; the canal 
should then be dissected out and its lower extremity ligated. As a pre- 
caution against the extravasation of urine into the peritoneal cavity, it 




Fig. 321. — " The sac extended from near the ensiform 
cartilage to the pubes." — Eeed (page 805). 



THE FEMALE URINARY APPARATUS 805 

is well to fix the pedicle of the urachus in the lower angle of the abdomi- 
nal incision. Before undertaking the operation, it is well to observe the 
admonition of Douglas, by making sure that the calibre of the urethra 
is sufficient to enable the urine to escape. 

Cyst of the urachus may result from an occlusion of both the 
umbilical and the vesical ends of the canal, secretion from its mucous 
surface, as described by Luschka, presently converting it into a reten- 
tion cyst. The fluid in these cases rarely, if ever, possesses any uri- 
nary elements, and must, consequently, be derived from the wall of the 
sac. In a case under Reed's observation, the sac extended from near the 
ensif orm cartilage to the pubes and forced the viscera from their normal 
positions (Fig. 321). The cyst was enucleated without opening the 
peritoneal cavity. Similar cases have been reported by Douglas and 
Alban Doran, and, previously, by Tait, Wolf, 111, Freer and others. 
The condition may be, and generally is, mistaken for an ovarian 
cyst. The facts, however, that it is immovable, that it occupies a 
median position, and that it has generally been a long time develop- 
ing, should suggest its urachal origin. Cysts of minor size generally 
elude detection until they are encountered incidentally in the course 
of an abdominal operation undertaken for another purpose. The 
treatment of these tumours is by abdominal section. The sac should 
be carefully enucleated. If ordinary precaution is taken in this 
manipulation, the peritoneal cavity need not be invaded — at least in 
the majority of cases. In a number of cases on record, it has been 
possible to enucleate these sacs without discovering a pedicle, thus 
showing that the connection between the urachus and the bladder had 
been broken up — probably in the course of evolution. 



CHAPTER L 

THE RECTUM 

Malformations — Examination — Displacements — General etiology of rectal disease 
— Relation of intrapelvic disease to disease of the rectum in women. 

The rectum is the lower segment of the alimentary canal and 
extends from the sigmoid flexure to the anus. It passes from opposite 
the left sacro-iliac synchondrosis, from left to right, to near the middle 
of the sacrum, whence it descends in the median line to the anus. It is 
narrower at its intestinal than at its anal end. Its upper portion is 
covered by peritoneum, which constitutes the mesorectum; its muscular 
layers are two in number, one of longitudinal fibres, beneath which are 
circular fibres comprising the sphincter ani internus. The rectum is 
lined with a mucous membrane which is united with the muscular layer 
by connective tissue and is covered with columnar epithelium, being 
raised into crescentic longitudinal folds called the columns of Morgagni, 
or the transverse rectal folds. The rectum is held in position by the 
mesorectum, by its connections with the circumrectal tissues in its 
lower third, and by the muscular apparatus embraced in the two layers 
of the pelvic floor. (See The Pelvic Floor.) 

Malformations of the rectum and anus are of more frequent occur- 
rence in male than in female children. They may, according to Boden- 
hamer (New York Medical Journal, May 25, 1889), consist of (1) a 
preternatural narrowing or stenosis of the anus at its margin, occasion- 
ally extending a short distance above this point; (2) complete occlusion, 
of the anal aperture by a simple membrane or by the common integu- 
ment or a substance analogous to it, more or less thick and hard; (3) 
absence of the anus with partial deficiency of the rectum, which ter- 
minates in a cul-de-sac at a greater or less distance above its natural 
outlet; (4) a normal anus associated with a rectum which, at variable 
distances above, is either deficient, obliterated, or completely obstructed 
by a membranous septum; (5) a rectum terminating externally by an 
abnormal anus located in some unnatural situation, e. g\, the sacral 
region, the perineum, within the fourchette, etc. (see Malformations of 
the Vulva), the abnormal anus thus formed being deficient in func- 
tional power; (6) the rectum opening into the bladder, urethra or 
vagina, or into a cloaca in the perineum with the urethra and the 
vagina; (7) a rectum normal in itself, but having the ureters, the vagina 
or the uterus opening abnormally into it; (8) complete absence of the 
806 



THE RECTUM SO 7 

rectum; (9) absence of both the rectum and colon and the termination 
externally of some other portion of the intestinal canal in an abnormal 
anus in some extraordinary part of the body; e. g., the umbilicus, the 
left iliac fossa, the lower part of the abdomen just above the symphysis 
pubis, below the scapula, and at the side of the face, for it has been 
known to occupy each of these situations. In the last-named class no 
normal anus ever exists. 

The prognosis of congenital malformations of the rectum and anus 
must depend largely upon the character of the malformation. As indi- 
cated in the preceding paragraph, these malformations vary greatly. It 
may be stated as a rule, however, that classes (3) and (4=) are of rela- 
tively more frequent occurrence than the others, and to them alone 
special attention will be given in this chapter. Whenever the malfor- 
mation is of such character as to obstruct the ftecal current, the condi- 
tion, if not overcome, must necessarily result in death. Without refer- 
ence to the classification of cases, out of 315 patients upon whom opera- 
tions had been performed, 160 recovered. This is an encouraging 
outlook, particularly when the desperate character of the cases is taken 
into consideration, and when it is remembered that many of the cases 
embraced in this table, compiled by Bodenhamer, were operated on in 
the preantiseptic era. Matas (Transactions of the American Surgical 
Society, 1897), in a valuable contribution on Anorectal Imperf oration, 
the condition designated in Bodenhamer's third and fourth classes, em- 
phasizes the fact that, in the development of this condition, the rectum 
and anus have simply failed to meet in the process of development. 
There is defective development of either the proctodeum or enteron, 
leaving the rectal pouch of the colon at a distance varying from a few 
millimetres to 5 or more centimetres from the perineum; or the enteron 
may be entirely absent and remain out of the pelvis altogether. 

The symptoms of imperforate anus consist in an absence of the 
fecal discharge and in restlessness, which may develop into spasms of 
the infant. Abdominal distention speedily ensues, but before this 
occurs, the vigilance of the nurse will have detected the true condition 
of affairs. The diagnosis of the condition within the pelvis, however, 
is far more difficult, if. indeed, it is not impossible. Probes, sounds, 
or guides, passed into the vagina or bladder, and the use of the aspirat- 
ing needle, are equally fallacious. 

Treatment consists in establishing the faecal current. This may 
be done, by establishing an anus either at its normal situation, or in 
the inguinal region. Matas gives it as an axiom, that it is the duty 
of the surgeon to presume that there is a rectal pouch in the pelvis and, 
if possible, to make an anal connection with it. This presumption is 
based upon the fact made apparent by Bodenhamer's table, namely, that 
the rectum and colon were totally absent in only 41 out of 165 cases. 
Whatever is done in these cases should be done early. Delay based 
upon the theory that infants can not resist traumatism, and that in 
these cases it is better to give them time in which to acquire strength. 



808 



A TEXT-BOOK OF GYNECOLOGY 



is a fatal and tragic fallacy. Delay under such circumstances means, 
not only the wasting of the child's strength, but the development of 
peritonitis followed by stercorsemia and death from exhaustion. The 
object of an operation should be to establish, if possible, an intestinal 
outlet in its normal situation in the perineal sacral region with 
sphincteric control. This should be accomplished by means of procto- 
plasty — i. e., by dissection down upon the rectal pouch and its fixation 
to the cutaneous margin. In making this section, it may be necessary 
to carry the incision well back to the coccyx or even up into the sacrum. 
If, after making this incision, it is found to be impracticable to attach 
the terminal portion of the colon (rudimentary rectum) to the external 
wound, it is justifiable in the emergency to attach the small bowel. 
Matas states that a median or lateral or exploratory abdominal section 
is indicated when, after the intraperitoneal exploration through a 
perineal sacral incision, it is evident that the terminal cul-de-sac of 
the rectum or any portion of the colon can not be brought down to the 
pelvic outlet, and that only the small intestine is available for procto- 
plasty. The aim of the operator, after making an exploratory abdom- 
inal incision, according to Matas, should be to guide the colon, the 

caecum or the most available 

HH»HH«NnHBHB loop of tllC ! I' Ml III. to tile pCl'l- 

neosacral wound, where it can 
be drained permanently with 
greater safety. The perineo- 
sacral anus, if the operation 
has been properly performed, 
is almost certain to be volun- 
tarily controlled in the course 
of time. Keen (Medical Mir- 
ror) suggests inguinal colos- 
tomy as the operation of choice 
in imperforate rectum, affirm- 
ing that it is safer to life and 
has the additional advantage of 
being done with facility, there 
being no groping in the dark 
in a narrow wound, while the 
time consumed is much short- 
er. In this suggestion, Keen 
follows in the footsteps of 
Chassaignac, Lannelongue and 
others, who, however, looked 
upon the inguinal operation as 

a tentative measure, to be followed later by a perineal operation for 

the establishment of an anus at its normal situation. 

The Examination of the Rectum. — Noninstrumentdl Proctoscopy. — 

The essentials of this method are a patient, an assistant, and an operator 



Fig. 322. — " The surgeon is to close his hands and 
to point his index fingers." — Martin (page 809). 



f 



THE RECTUM 



809 



having at least one finger on each hand. The patient is to be put into 
the knee-chest posture; the assistant is to place and to hold the patient; 
and the surgeon's fingers are to be used to open the anus, all in the 
following manner, to wit: 

1. The patient is to be completely anaesthetized as she lies on 
her back, and then turned toward the assistant and into the Sims 
posture. 2. The assistant is to station himself at the patient's knees. 
In his left hand he is to grasp 
the patient's feet. He is to 
lean himself against the pa- 
tient's knees. He is to pass 
his right arm under the pa- 
tient's hips. ~Now steadying 
the feet and bearing himself 
firmly against the patient's 
knees, with his right arm he is 
to lift the hips and pull his 
subject into the knee-shoulder 
posture. 

Here, securely held in the 
embrace of the assistant, the 
patient is to be balanced on 
her perpendicular right thigh, 
where, throughout the whole 
time of the surgeon's manipu- 
lations, she must be steadily 
held. (A Simplest Proctos- 
copy, Martin, Journal of the 
American Medical Association, 




August 27, 1898). 3. The 
surgeon is to close his hands 



Fig. 323. — " The wrists are to be crossed . . . and 
the nails of the index fingers placed one against 
the other." — Martin. 

and to point his index fingers 

(Fig. 322). The wrists are to be crossed, the hands placed back against 
back, and the nails of the index fingers placed one against the other 
(Fig. 323). The surgeon is to lubricate these fingers and gently insinu- 
ate them through the anus and place their ends beyond the borders of 
the levatores ani. This accomplished, the anus is to be kneaded and 
divulsed in the direction of the ischial tuberosities, by the surgeon 
forcibly parting his fingers as is shown in the accompanying illustration 
(Fig. 322). Under this manipulation the rectum becomes atmospheric- 
ally inflated. 

Now, provided the surgeon lowers his head to the level of his fingers 
and then rises again, or stoops, or moves a little from side to side, he 
may command under his eye a view of the atmospherically inflated 
rectum to the depth of 6 or 8 inches (15.24 or 20.32 centimetres), 
and, in some instances, he may behold even a part of the sigmoid flexure. 
It is possible for the operator to manipulate his patient and to finish 



810 A TEXT-BOOK OF GYNECOLOGY 

his inspection within two and a half or three minutes, provided the 
patient is in a state of complete anaesthesia. 

If this method is practised, as it may be with facility by the gen- 
eral practitioner, the greater number of rectal diseases may be instan- 
taneously diagnosticated. But at diagnosis the achievement of the 
simplest proctoscopy ends, for the reason that the operator's hands 
are so full of his patient he can do nothing at all for the disease that 
he may have discovered. 

In some conditions, and amid some circumstances, the rectum will 
not become inflated. If there is a close stricture of the rectum; if 
there is malignant growth or other disease of the rectum, by means 
of which the gut's coats have become extensively filled and fixed with 
an organized plastic exudate; if for some reason the intra-abdominal 
pressure is abnormally increased, as it may be by the bearing down of 
the patient, by enormous intestinal flatus, or by ascites; or if there is 
an impinging uterus, an extrarectal growth or extensive infiltrating 




Fig. 324. — "A section through a hardened rectum." — Martin. 

disease of the contiguous textures, rectal inflation by this method, or 
by any other which is governed by the same principle, is a physical 
impossibility. But this need not baffle the man bent on seeing by in- 
strumental aids. 

Practised as described, when not embarrassed by the exceptions 
specified, this method will achieve its purpose and reveal to the surgeon 
that the transverse diameter of the rectum is variable. Martin has 
demonstrated this variation by means of a section through a hardened 
rectum, with the body in Martin's posture (Fig. 324). While in some 
places it is not more than an inch (2.54 centimetres), in others it is more 
than four times as much, in diameter. 

The rectum may present to the eye of the imaginative observer 
the appearance of a chain of urinary bladders, communicating one 
with another by means of irregularly elliptic openings set at varying 



THE RECTUM 



811 



axes, and bounded by the nonparallel borders of the rectal valves. In 
the normal rectum, the air pressure smooths the mucous membrane 
evenly over the entire surface of the gut. The normal mucous mem- 
brane of the so-called ampulla appears at first wet and of a shining 
bluish gray. As it dries, under the influence of gravitation the blue 
venous tint fades out of the gray, and the wall becomes pink-tinged; 
presently, it assumes the appearance of parchment, and sometimes it 
appears painted at rare intervals with ramifying little arteries which 
are crowded and overlapped by the larger companion veins; the latter 
are less arborescent and more suddenly dive and disappear in the bowel 
wall. In time, there comes a sheen over all, and the vascular pictures 
fade. These phenomena appear exactly as described only in the healthy 
rectum; in the diseased organ the colour varies much. 

Should the operator deviate from the prescribed directions for the 
manipulation of his fingers, and so twist his hands as to divulse the 
anus in the antero-posterior direction instead of laterally, he invites 
defeat upon himself; for, in the male, the fixation of the perineum 
and the immobility of the coccyx interfere with the requisite dilatation; 
while in the female, the extreme mobility of the perineum, and particu- 
larly the backward displaceability of the coccyx, will allow such traction 
to be made upon the leva- 
tores ani as to pull their 
inner borders parallel and 
almost together; and, in 
consequence, the wider 
the female's anus is 
opened antero - posterior- 
ly, the closer it shuts 
laterally to rob one of 
one's view. 

Instrumental Proctos- 
copy. — Special parapher- 
nalia and much practice 
in their use are necessary 
for a rapid, painless and 
complete inspection of 
the rectum. 

The chair which is 
shown in the illustra- Fig. 
tions * was designed by 
Dr. T. C. Martin, of 

Cleveland, to facilitate the placing of the patient in a new posture 
equivalent to the knee-chest posture. This improvement on the Yale 




-" Thomas Charles Martin's anoscope." 
— Martin (page 812). 



* Much of the mechanism of this excellent invention is necessarily omitted in 
the small drawings to which alone space can be given. The reader is referred to 
Dr. Martin for further particulars. — Editor. 



812 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 326. — " The distinctive feature of this anoscope is the peculiar 
form of its obturator." — Martin. 



chair consists of a knee-piece which is fixed to the left arm, of a mechan- 
ism attached to the running-gear which provides for the new move- 
ments, of a shoulder-strap, and of an illumination apparatus which is 
susceptible of adjustment in an infinite number of positions. 

Thomas Charles Martin's anoscope (Fig. 325) consists of a short 
cylindrical tube open at the ends. It is 2 inches (5.08 centimetres) 

in length and f 
of an inch (2.22 
centimetres) in 
diameter. The 
proximal end is 
provided with a 
trumpet - shaped 
expansion and a strong handle. The distinctive feature of this ano- 
scope is the peculiar form of its obturator (Fig. 326), which has a 
capacity for a multiplicity of uses. 

The obturator consists of a hard-rubber cylinder, in the middle of 
which is fixed a brass tube for purposes of irrigation. Its surface is 
fluted in such a manner that it may be made to lock in any of several 
positions upon a tubercle within the cylinder. These flutes also pro- 
vide for escape from the rectum 
of fluids and gases under certain 
conditions. The contracted neck 
near the distal end of the obtu- 
rator provides a cup to facilitate 
the application of ointments to 
certain rectal areas (Fig. 327). 
This contracted neck is a feature 
which contributes to the instru- 
ment's usefulness as a means for 
irrigation; providing, in the one 
case, a self-retaining direct-flow 
irrigator, and, in the other case, 
when locked in proper position, 
an unobstructed return-flow irri- 
gator. Platinum pins connect 
the centrally placed brass tube 
with the surface of the neck of 
the obturator, thus making the 
instrument an anal electrode. 
The proctoscope (Fig. 328) is 
of the same diameter as the anoscope and is 4 inches (10.16 centi- 
metres) in length, which, because of the displaceability of the pelvic 
floor, is usually sufficient for it to reach as high as the promontory 
of the sacrum, except in some special instances. 

Special preliminary preparation of the patient is ordinarily not re- 
quired, as the usual condition of the rectum is that of emptiness. In 




Fig. 327.—" The contracted neck . . . provides 
a cup to facilitate the application of oint- 
ments."— Martin. 



THE RECTUM 



813 



some cases, however, it facilitates the inspection if the patient employs 
rectal lavage an hour before the examination. 



I: The patient should be required to sit on 
her body turned to the left and facing the 



The Technique. — Step 
the operating chair with 
knee-board. The right 
knee should be crossed 
over the left knee, the 
left arm should embrace 
the right border of the 
chair-back, or it may be 
folded at the side as for 
Sims's posture. The small 
pillow should be held in 
the patient's right hand, 
and against and upon her 
left shoulder (Fig. 329). 

Step II requires that 
the chair be changed to 
the horizontal position and the light fixture adjusted (Fig. 330). This 
movement brings the patient into Sims's semiprone-semiflexed posture 
without requiring any movement whatever on the part of the patient 




The proctoscope." — Martin (page 812). 




Fig. 329. — u The patient should be re- 
quired to sit on the operating chair." 
— Martin. 



Fig. 330. — " Step II requires that the chair 
be changed to the horizontal position." — 
Martin. 



after she is properly seated. In this posture the external anus and 
fixed rectum are to be examined. 

(a) Digital and ocular inspection should now be made of the anal 
verge, the external anus, and the superficial ischiorectal space at a mo- 
ment when the patient is relaxed, and again when she is bearing down. 



814 



A TEXT-BOOK OF GYNECOLOGY 




Fig. 331.—" The chair should be tilted."— Martin 
(page 815). 



(b) Digital examination of the fixed or anal rectum, also, should be 
made a preliminary to the introduction of the anoscope. 

(c) The anoscope 
should be gently pressed 
into the anus in the direc- 
tion of its axis till the 
sphincters relax to receive 
it. The introduction of 
the instrument may be 
much facilitated by hold- 
ing its lubricated end 
against the sphincter and 
requiring the patient to 
bear down; bearing down 
expands the ental sphinc- 
ter, relaxes the levator ani, 
thins the pelvic floor or 
shortens the fixed rectum, 
and presses the rectal 
sphincter over the instru- 
ment — in other words, the 
patient's anus is made to 
climb down upon the instrument. After the introduction of the ano- 
scope, its obturator should be removed and the inspection made. The 
observations should 
be made coincident 
with the withdrawal 
of the anoscope. In 
instances of extreme- 
ly sensitive ani, hy- 
podermic injection 
into the sphincters of 
10 or 20 minims of 
one - tenth - of - one - 
per-cent solution of 
cocaine will render 
anoscopy painless. 

A desire for pre- 
cision requires that 
lesions of the fixed or 
anal rectum should 
be noted as occupy- 
ing a given quadrant, 
and as situated at a 
given zone, 




Fig. 332. 



The extreme oblique lateral position." — Martin 
(page 815). 

e. g., a 

circumscribed disease may be described as situated at the ental sphincter 
zone and in the left lateral quadrant. 



THE RECTUM 



815 



Fig. 333.—" The hook."— Martix. 




Step III requires (a) that the shoulder strap should be placed and 

fixed to the chair, that the knees should be drawn up so that the thighs 

are at a right angle to the 

length of the chair-top, and 

that the chair should be tilted 

(Fi£. 331) to the extreme ob- 
lique lateral position (Fig. 332). 

The leg-foot-board should now 

be lowered, and the operator's 

stool placed in position. The 

illumination apparatus should next be adjusted as illustrated. In this 
new posture, which is equivalent to the knee-chest pos- 
ture, the abdominal rectum is to be examined. 

(b) Introduction of the proctoscope requires sup- 
ported eversion of the buttocks and steady gentle pres- 
sure of the well-lubricated instrument upon the anus 
in the direction of the umbilicus, until the sphincters 
are felt to yield; or the patient may be required to bear 
down to take the speculum. As the instrument enters 
the inflatable movable rectum, it should be pointed 
toward the promontory of the sacrum and subsequently 
into the sacral hollow. The withdrawal of the obturator 
is followed by atmospheric inflation of the rectum. 

1(c) The operator should observe the degree of rectal 
I distention, the situation and number of the rectal valves, 
£ their propinquity to one another when passive, and the 
5 relation of one valve to another at the time of the 
£ patient's bearing down. Under pressure of the procto- 
M scope, if possible, or the hook (Fig. 333), if necessary, 
J each valve should be effaced or displaced, and in regular 
g order each of the rectal chambers should be carefully 
| inspected. A proctoscopic mirror may be necessary for 
^ viewing the supravalvular surfaces (Fig. 334). 
< The examination being finished, we proceed to — 

1 Step IV: The proctoscope should be withdrawn, the 

2 illumination apparatus fixed in the first position, the 
2 leg-foot-board lifted to its place, the lever extended, the 
^ crank turned, and the chair carried back to the hori- 
zontal and upright positions; the patient being thus re- 
turned to her feet by the execution in the reverse order 
of the several steps described. 

This method of inspection does not subject the pa- 
tient to struggle or strain and need excite no embar- 
^5 rassment. 

Observation by this method teaches that, in nearly all 
cases of disease at the anus, there is congestion of the rectal mucous mem- 
brane, and that, not unusually, a diffused proctitis attends anal disease. 



816 



A TEXT-BOOK OF GYNECOLOGY 



Those cases in which there is no apparent lesion at the anus, and 
which are in a perfunctory way sometimes declared to be catarrh of the 
rectum, will at once have their real cause, such as a high-up rectal poly- 
pus or a congenital or organic stricture or ulceration, positively diag- 
nosticated, and will be made accessible for intelligent treatment. 

New growths or ulcerations may be seen and, by means of a long- 
handled curette, scrapings made, in order that the microscopist may 
determine their exact character. 

Vesico-rectal, vagino-rectal, and deeper rectal fistulse, are often ap- 
parent at a glance, but, in any case, may be discovered by the use of 
the proctoscopic mirror. 

The existence of stricture of the rectum need no longer be regarded 
as only doubtful, and this method proves positively, even to the casual 
observer, how fallacious is the rectal sound as usually employed in the 
diagnosis of stricture. It has been repeatedly shown how easy it is 
for an entering or returning bulb-sound to be caught and held by the 
rectal valves, and to elicit those signs which are generally considered 
diagnostic of organic stricture of the rectum. 

The rectal valve constitutes the chief topographical feature of the 
abdominal rectum. Its histologic character indicates it as the typical 
anatomic valve (Fig. 335). The attached border of each valve spans a 
little more than half the circumference of the rectum, and its free 
border projects half way across the diameter of the inflated rectum. 
Thus, what has heretofore been regarded as a cavernous ampulla, is 

seen to be divided in- 
to several chambers. 
There are as many 
chambers in the rec- 
tum as there are rec- 
tal valves. The num- 
ber of rectal valves is 
variable. Some sub- 
jects have but two, 
others have four, 
but 90 per cent of 
persons possess three. 
The uppermost valve 
is invariably situated 
at the juncture of the 
rectum and the sig- 
moid flexure, and is usually on the left wall; the next is on the right, 
and the lowermost on the left wall. The positions of the loiter two 
valves are sometimes anterior and posterior respectively. It must be 
readily seen that the newer methods of rectal inflation for rectal in- 
spection will determine newer notions of the topography of this part, 
and will justify consideration of the lowermost chamber as the first 
rectal chamber; of the cavernous area beyond the first valve and be- 




Fig. 335. — " The typical anatomic valve." A, mucous mem- 
brane ; 7?, fibrous tissue ; (?, bundles of circular muscular 
fibres ; D, F, arteries ; 7?, G, veins ; 77, areolar and adipose 
tissue. — Martin. 



THE RECTUM 



817 




Fig. 336. — " The ancient arbitrary division of the rectum 
should be abandoned." (Laparosymphysiotorny, show- 
ing the rectum packed with scybala.) — Martin. 



low the second, as the second chamber; and of the upper chamber as 
the third or perhaps the fourth, according to the number of valves. 
The ancient arbitrary division of the rectum by the anatomists into 
upper first, middle 
second, and lower 
third parts, should be 
abandoned (Fig. 336). 

If this method of 
ocular examination 
is practised, there 
need be no longer 
any excuse for calling 
an undiagnosticated 
disease of the rectum 
an "obscure disease"; 
and, whatever the 
disease present, this 
method makes it sus- 
ceptible of demon- 
stration to the pa- 
tient's physician or 

attendant friend. There is no necessity whatsoever that the diag- 
nosis of rectal disease be taken on faith. (Complete Inspection of the 
Rectum, Thomas Charles Martin, M. D., American Gynecological and 
Obstetrical Journal, December, 1898.) 

Displacements of the rectum in women may be classified as (a) 
anterior, (b) posterior, and (c) prolapse. Anterior displacement con- 
sists of the sacculation forward of the anterior wall of the rectum. 
This constitutes the condition of rectocele (see Eectocele), or more 
specifically anterior rectocele. It necessarily implies an equal displace- 
ment of the posterior wall of the vagina. The condition is generally 
induced by either dilatation of the vaginal outlet or injury of the 
pelvic floor. It is treated as prescribed in the chapter on Eepair of 
Surgical Injuries of the Floor of the Pelvis. 

Posterior displacement of the rectum consists in the sacculation, 
posteriorly, of the posterior wall of the rectum, and is, in reality, a 
posterior rectocele (Fig. 33 T). This condition which is not frequently 
recognised, is, nevertheless, one of relatively common occurrence. 
Its symptoms consist of more or less rectal tenesmus and difficulty in 
defecation, there being a constant sense of the presence of residual 
faeces after an effort at dejection. If the bowel is loaded with hard- 
ened faecal matter, much difficulty is experienced in discharging it, the 
effort being attended with a feeling of retro-anal protrusion. If a 
patieut afflicted with this condition is placed in either the dorsal or 
the semiprone position and is asked to strain, a fulness behind the 
anus will be apparent. Eectal exploration by the linger will reveal a 
posterior sacculation of the rectum, just within the external sphincter, 
53 



818 



A TEXT-BOOK OF GYNECOLOGY 




and associated with a diminution or a disappearance of the normal 
constriction due to the proper action of the levator ani muscle. The 
pathology of this condition is essentially that of the dilatation of the 
rectum and is due to either a relaxation or an injury of the deep mus- 
cular layer of the pelvic floor. 
When the levator ani has once 
been damaged, and the rectum 
has been deprived of its support, 
there occurs more or less descent 
of the bowel. This descent is aug- 
mented by an effort to defecate. 
The external sphincter fails to act 
properly because the descending 
faecal matter is to a certain extent 
diverted from its course and conse- 
quently fails to exercise the proper 
dilating influence upon the exter- 
nal muscle. The treatment con- 
sists (1) in restoring the integrity 
of the parts upon the damage to 
which the rectal displacement de- 
pends, and (2) in restoring the rec- 
tum itself to its normal position. 
Eeed has operated in these cases by 
means of the Emmet operation for 
deep lacerations of the perineum, 
supplemented by the following steps: An incision is made transversely 
midway between the anus and the tip of the coccyx, care being taken 
to avoid the external sphincter. This incision, which is about an 
inch and a half long, but which may be longer, if required, is carried 
down to the posterior wall of the rectum, which is then dissected up 
to a point beyond the levator ani. The sacculated bowel is then lifted 
above the levator to which it is attached by a few interrupted catgut 
sutures. The external incision is then closed. Harris's operation for 
deep injuries of the muscular floor of the pelvis may be substituted 
with advantage for the Emmet operation in these cases. 

Prolapsus of the rectum may be either (1) partial, or (2) com- 
plete. By partial prolapse is implied merely a descent and extrusion 
from the anus of the mucous membrane of the rectum, and it is the 
condition generally designated prolapsus ani; complete laceration im- 
plies the descent and extrusion from the anus of the entire rectal 
walls, and is the condition ordinarily designated prolapsus recti. Par- 
tial prolapsus occurs, for the most part, in children, and is caused by 
efforts at defecation, either in constipation, or in diarrhoea associated 
with rectal irritation and consequent tenesmus. Complete prolapse 
occurs more frequently in adults and is the result of straining at stool, 
either from constipation, vesical tenesmus induced by stone in the 



Fig. 337. 



-" Posterior rectocele."- 
(page 817). 



-Reed 



THE RECTUM 819 

bladder or other causes, uterine displacements caused by polypi, etc. 
Injuries of the pelvic floor, relaxation of the muscular apparatus of 
the rectum, and general enteroptosis, are to be considered as predispos- 
ing causes. The symptoms of prolapsus of the rectum, whether com- 
plete or incomplete, consist in the sudden appearance of a mass just 
outside the anal orifice, which, upon examination, will be found to 
consist of folds of mucous membrane. If this extrusion is recent and 
the sphincteric contraction is not extreme, the mass may present a 
ruddy hue, but, if the ease has been one of long standing, it may be 
dark in appearance, or even gangrenous. The diagnosis is self-evi- 
dent, but is easily confirmed by introducing the anointed finger into 
the anus. 

The treatment may be either (1) palliative or (2) radical. The 
palliative treatment consists in the immediate return of the parts. 
This is accomplished in children by placing the patient upon her side, 
anointing the fingers of one hand with some sterilized preparation, 
and then by gentle pressure replacing the extruded mucous mem- 
brane. An anal compress may be applied following the replacement 
of the bowel. In some cases, however, the extrusion may have ex- 
isted for so long a time, and the sphincteric constriction may have 
been so extreme, that strangulation with death of the structures may 
have ensued. It is to be remembered that, both in complete and 
incomplete prolapse of the rectum, spontaneous amputation of the 
extruded part occasionally occurs, resulting in the cure of the patient. 
When the condition has gone to the stage that threatens this result, 
intervention because of its probable danger, is of questionable value. 
By the slow amputation of the extruded rectum, there occurs a fixa- 
tion by inflammatory process of the remaining intra-anal segment ; 
and it is obvious that, if this fixation is disturbed, there may occur 
a retraction of the upper portion of the rectum, resulting, in the 
event of cure, in the deposit of a zone of cicatricial tissue and the 
development, later, of intractable stricture. If, however, in the event 
of complete prolapsus, there is a reasonable prospect of saving the 
bowel, the patient should be placed in either the knee-chest or the 
semiprone posture, and the bowel should be replaced by digital 
manipulation. If this is not practicable because of intractable sphinc- 
teric spasm, an anaesthetic should be given to the patient. Divulsion of 
the sphincter, which would facilitate the reduction of the bowel, is 
not desirable, for the reason that the sphincter, in its full tone and 
integrity, is required to maintain the replaced bowel in position. For 
the purpose of restoring the normal contractility of the relaxed bowel, 
it has been recommended to cauterize it in spots with either the silver 
nitrate or the cautery. A rectal tube of soft rubber may be used to 
maintain the reduction. In exceedingly obstinate cases, a V-shaped 
piece has been removed from the sphincter, the apex of the letter 
pointing backward toward the coccyx, the sphincter being restored 
after reduction of the bowel. Jaennel, of Toulouse (Bulletin de 



820 A TEXT-BOOK OF GYNECOLOGY 

VAcademie de medecine), believes that rectal prolapse is due, in many 
cases, to a weakening of the ligaments that hold these parts in posi- 
tion, especially the mesocolon and the mesorectum, establishing the 
condition to which allusion has already been made as that of enterop- 
tosis. He treats this condition by performing an ordinary colotomy. 
The sigmoid flexure is sought for, drawn upward, and fixed to the 
abdominal wall by sutures. The next step is to establish an artificial 
anus, which will afford the necessary rest until firm adhesion has oc- 
curred. The opening is not closed until the flexure has become firmly 
adherent. The operation has been performed with entire success in 
one case, the patient being cured in two months. It was performed 
in three sittings and this is one of its disadvantages ; besides, it is not 
easy to find the sigmoid flexure. It has the advantage over other 
operations for rectal prolapse, however, in that it removes the cause 
of the trouble and is less dangerous. It is contraindicated in recent 
cases of medium severity or in old cases in which the prolapse is due 
to inflammatory peritoneal adhesions. 

General Etiology of Rectal Disease. — Because of its peculiar func- 
tion, the rectum frequently becomes diseased. There are so many 
factors entering into the etiology of rectal disease that we shall 
not attempt to mention them all. There is little doubt that the 
upright position assumed by man is a predisposing cause of hemor- 
rhoids, because a large amount of blood is thereby thrown upon the 
valveless veins of the rectum. The most common of all causes, is 
constipation induced by irregularities in sleeping, eating, exercising, 
and attending to the calls of Nature. Fissure is usually the result of 
constipation in consequence of a tear made in the mucous membrane 
during the passage of hardened faeces; ulceration, because of pressure 
of the faecal mass on the blood vessels causing necrosis; hemorrhoids 
ensue because of pressure interfering with the return flow of blood 
and, further, as a result of straining coincident with their expulsion; 
prolapsus and invagination are of frequent occurrence in the consti- 
pated on account of straining and the dragging down of the bowel 
by the faeces. The mucous membrane of the rectum is very fragile 
and is occasionally injured sufficiently by the faecal concretions to set 
up a proctitis which may confine itself to the rectum or extend into the 
circumrectal tissue causing ischiorectal aoscess and fistula. Neuralgia 
of the rectum is now and then a symptom of costiveness and results 
from the nerves being caught between bony structures on the one 
hand, and a faecal mass on the other. 

Strong drink and other forms of dissipation are responsible for 
many of the ailments in this locality. Persons suffering from pruritus 
and hemorrhoids are invariably worse after a spree. The continued 
use of purgatives is a common cause of rectal disease, owing to the 
straining and irritation of the mucous membrane induced by them. 
Chronic diarrhoea may incite a prolapsus, ulceration, or hemorrhoids, 
on account of the frequent stools, tenesmus, and passage over the 



THE RECTUM 821 

sensitive membrane of irritating discharges. Threadworms, pediculi, 
and anal eczema, not infrequently start an itching about the anus 
which is difficult to arrest. Constipation, stricture, and fissure, in 
young children can usually be traced to a congenitally narrow anus. 

Foreign bodies reaching the rectum by way of the mouth or anus 
cause considerable suffering and may require an operation to remove 
them. Traumatism caused by hardened faeces or operation is respon- 
sible for many of the afflictions in the terminal colon. The Whitehead 
operation, when primary union is not obtained, results in many un- 
pleasant sequelae such as ulceration, stricture, fistula, abscess, pruritus, 
and incontinence; other operations may do the same, but only at rare 
intervals. Many injuries of the rectum follow the frequent and careless 
introduction of the syringe nozzle by the person in the habit of taking 
enemata. 

Occupation is an important factor in the causation of rectal dis- 
ease. Persons whose employment requires a sedentary life, their 
being constantly on their feet, or irregular hours for eating and attend- 
ing to Nature's demands, are frequent sufferers from hemorrhoids and 
fissures. The upright position assumed by conductors, brakemen, 
engineers, and motormen, combined with the irregular jarring motion 
of trains and street cars, is a predisposing cause of rectal disease. On 
account of the vascular arrangement, obstructive diseases of the liver 
and heart are usually accompanied by hemorrhoids. Tumours in, or 
displacements of, neighbouring organs, as an enlarged prostate or a 
retroverted uterus, are the cause of many patients going to the proc- 
tologist. The function of the rectum renders it liable to injury, thus 
preparing the way for infection, local and general, by the various 
micro-organisms contained within its walls. Venereal diseases com- 
mon in the sexual organs are found also in the rectum and about the 
anus of those who practise pcederasty (rectal intercourse), but with 
less frequency. Paederasts are recognised by their relaxed sphincters 
and the funnel shape of the anus. The large rectal veins in passing 
from without the bowel to the mucous membrane within, go through 
muscular buttonholes. It is believed by some that frequent muscular 
contraction around the veins results in their enlargement below, ter- 
minating in piles. Occasionally the levator ani and external sphincter 
become hypertrophied and irritable as the result of a faecal mass 
pounding upon them, and thus interfere with defecation or cause 
much pain by their frequent contractions. Undue force exhibited by 
the abdominal muscles will produce an engorgement of the rectal 
veins ; this can be demonstrated by having a patient suffering with 
hemorrhoids strain down, when they will immediately enlarge and 
turn blue. Houston's folds sometimes become hypertrophied, result- 
ing in constipation and allied ailments. 

The Relation of Intrapelvic Disease to Disease of the Rectum in 
Women. — Intrapelvic disease in women may disorganize the function 
or compromise the integrity of the rectum. Such results are the 



822 



A TEXT-BOOK OF GYNECOLOGY 



product of (1) pressure upon the rectum by means of a displaced 
uterus or ovary, or of a tumour or adventitious peritoneal band; (2) 
the extension of an inflammation-, (3) adhesion of a viscus to the 
rectum or sigmoid flexure, or of adhesion of one part of the gut to 
another. 

Pressure on the normal rectum of a retroposited but nonadherent 
uterus will not often obstruct the descent of the faeces provided urina- 
tion precedes the attempt at defecation. An ovary prolapsed into the 
cul-de-sac will interfere with defecation, inasmuch as its sensitiveness to 
pressure arrests the voluntary effort of the patient. An intrapelvic 
tumour, nonadherent to the rectum, obstructs defecation in propor- 
tion as it limits the dilatation of the rectum; the same may be said 
of an adventitious band of peritoneum about the rectum. The pres- 
ence of any of these con- 
ditions may interfere 
with the nutrition of the 
rectum or obstruct its 
circulation and provoke 
proctitis, ulceration, and 
hemorrhoids, and render 
the rectum prone to other 
diseases. 

Inflammation of any 
pelvic viscus, pelvic peri- 
tonitis, appendicitis, or 
pelvic cellulitis, by reason 
of the usually concomi- 
tant proctitis and infil- 
tration of the rectal 
valves, produces a transi- 
tory diarrhoea, constipa- 
tion, or obstipation; if 
resolution is imperfect, 
the obstipation will be- 
come chronic — in such a 
condition there is always 
a remote possibility of 
acute and complete ob- 
struction from inflamma- 
tion and oedema of the 
affected rectal valve. In- 
trapelvic abscess finds its 
quickest avenue of escape into the rectum. This event is character- 
ized by amelioration of the patient's symptoms and subsequent puru- 
lent discharge from the rectum. Proctoscopy reveals a more or less 
general proctitis and, at the vicinity of the fistula, an oedema and 
corrugation of the mucous membrane; if the perforation is not at 




Fig. 338. — " Adhesions to the rectum, and particularly 
to the sigmoid flexure, may arrest the descent of 
faeces." (The dotted portion shows an adhesion 
which has been broken up.) — Maetin (page 823). 



THE RECTUM 823 

once visible, pressure on the abdomen will cause pus to be ejected at 
its site. 

Adhesions to the rectum, and particularly to the sigmoid flexure, 
may arrest the descent of solid or semisolid faeces without contracting 
the bowel's lumen; inasmuch as the immobilization of a portion of an 
organ which is essentially peristaltic, robs that portion involved, of its 
intrinsic power of propulsion of its contents (Fig. 338). Nonperistalsis 
of the rectum by reason of adhesion to a pelvic viscus is, however, but a 
minor factor in the resulting obstipation, because the expulsion of 
solid and semisolid faeces is in the main accomplished by the volun- 
tary mechanism. In case of such adhesion, the adherent organ inter- 
feres with the necessary dilatation of the rectum, and, furthermore, 
the voluntary forces of defecation drive the adherent organ into the 
sacral hollow ahead of the faecal mass. 

Gant observes that disease occurring in either the genitalia or the 
rectum frequently manifests itself in the other organ because of the 
intimate relation of the veins, nerves, muscles, and lymphatics, sup- 
plying them. There are certain diseases that interfere with the cir- 
culation, and result in congestion or anaemia of the rectum, genitals, 
or both. Pain from disease in the vagina, uterus, ovaries, tubes or 
bladder, is frequently reflected to the rectum and vice versa. Fissure 
or ulceration of the rectum, exciting contraction of the external 
sphincter or levator ani muscles, causes similar contractions in the 
vagina and vulva. Pain following operations about the perineum and 
vagina is less when the sphincter is divulsed. Because of these fre- 
quent muscular contractions, the arrangements of veins in plexuses, 
and the intimate relation of the lymphatics, the exchange of infections 
from the genitals to the rectum, and vice versa, is quite frequent. 
Careful examination should be made both of the genitals and the rec- 
tum in all obscure diseases affecting either. 



CHAPTER LI 

INFECTIONS OF THE RECTUM 

Inflammation — Periproctitis ; Ischiorectal abscess — Gonorrhoea — Syphilis — Tuber- 
culosis — Surgical conditions resulting from infections — Anal ulcer or fissure — 
Ulceration of the rectum — Fistula — Stricture. 

Infections of the rectum may be classified as (a) mixed, and (b) 
specific. Mixed infections, i.e., those in which the various pus-formers — 
e. g., Staphylococcus pyogenes aureus, the various streptococci, and occa- 
sionally the migrated Bacillus coli communis — are found, are those that 
are manifested in the superficial inflammations, both catarrhal and fol- 
licular, and in deeper-seated inflammations, as periproctitis and ischio- 
rectal abscess. The specific infections which will be considered in 
this connection are, gonorrhoea, syphilis and tuberculosis. 

Inflammation of the rectum and sigmoid is a common ailment, and 
one easily recognised and treated by means of the colon tube. Ordi- 
narily, the inflammation is confined to the mucous membrane, but 
occasionally it extends through the muscular coats causing periproc- 
titis, ischiorectal abscess, and fistula. It is frequently the result of a 
more serious disease; occasionally, it is due to diphtheria and a mem- 
brane forms; again, because of proximity of the vagina to the rectum, 
it is caused by gonorrhoeal infection; while, in tropical countries, it 
is often the result of a dysentery. Usually the mucous membrane will 
be inflamed and dry — atrophic catarrh — or spongy and smeared over 
with an abundance of mucus — hypertrophic catarrh. It may be either 
acute or chronic. Children are subject to the acute, and old persons to 
the chronic form; the former because of diarrhoea, and the latter, as a 
consequence of loss of tonicity resulting in faecal accumulations. It 
may be caused by exposure to cold, sitting on damp steps, or traumatism 
due to swallowing a hard indigestible substance or to an operation. 
Not infrequently, it is brought about as the result of an irritable dis- 
charge from a stricture, cancer, ulceration, polypus or diarrhoea. Again, 
it sometimes follows the administration of drugs such as large doses of 
mercury and arsenic and strong purgatives. 

Symptoms. — The symptoms of inflammation of the rectum and 

sigmoid may be briefly summed up as follows — viz., severe tenesmus 

and sense of weight and fulness in the rectum; sensations of heat, 

fulness, and soreness on pressure; frequent discharges of mucus and, 

824 



INFECTIONS OF THE RECTUM 825 

occasionally, of pus; spasmodic and unsuccessful attempts to evacuate 
the bowel. "When due to atrophy following catarrh, the skin and 
mucous membrane about the anus are dry, harsh, and full of cracks; 
when to hypertrophy associated with catarrh, there will be a constant 
moisture in this locality. There is often pruritus due to irritating sub- 
stances getting into the cracks, and to irritation of the skin and mem- 
brane caused by the discharge. In the acute stage there is a desire to 
micturate often, and, occasionally, incontinence of urine. Because of 
straining and frequent stools, a prolapse of the mucous membrane is 
not uncommon. If the inflammation is complicated by ulceration, 
bleeding may be a symptom, or faecal matter may get under the mem- 
brane and start an abscess resulting in fistula. In general, any symp- 
tom present in inflammation of any part of the intestine may be pres- 
ent here, such as radiating and reflected pains and slight elevation 
of the temperature. 

Prognosis. — When taken in hand early, inflammation of the rectum 
and sigmoid is easy to control. An acute attack may last one, two, or 
three weeks, and the chronic form indefinitely, depending upon the 
cause and its removal. When it has not existed more than a few 
weeks, the most apparent change in the former, barring the congested 
appearance of the mucous membrane, is the oozing of blood from many 
points when the speculum or colon tube is introduced. In cases of 
long standing, the mucosa becomes thickened, indurated, and loses 
its sensibility in a measure, so that a considerable amount of faeces may 
collect in the sigmoid and upper rectum before a warning is given 
of an approaching stool. Inflammation, when allowed to run an un- 
interrupted course, usually results in ulceration and stricture. 

Treatment. — Eemove at the earliest opportunity the source of irri- 
tation. Discard harsh and indigestible foods for milk, soft-boiled eggs, 
soups, beef juice, and other nourishing fluid and semisolid foods. 
Insist upon the discontinuance of eatables fried in grease, and those 
that are highly seasoned, and at the same time stop all alcoholic 
drinks. These patients must have regular hours for eating, sleeping, 
exercising, and attending to the calls of Nature. Keep the stools soft 
with two ounces of Carabana water taken before breakfast, and clear 
the bowel of offending scybala, by massage, high enemas, Epsom 
salts, Seidlitz powders or other mild laxatives, and, above all, discon- 
tinue irritating purgatives. Keep the patients in bed as much as their 
circumstances will permit. The medical treatment consists in apply- 
ing soothing, antiseptic, and astringent solutions, emulsions and pow- 
ders, directly to the affected part by means of the colon tube, applica- 
tor, atomizer, and insufflator. The remedies which give the most sat- 
isfactory results are the nitrate of silver, balsam of Peru, sulphate of 
zinc, lead, alum, argonin, and ichthyol, alone or in combination. Giant 
is partial to the fluid extract of krameria, half an ounce to two ounces of 
distilled water, thrown into the sigmoid or rectum and allowed to 
remain there as long as it can with comfort to the patient. In aggra- 



826 A TEXT-BOOK OF GYNECOLOGY 

vated cases, the krameria may be increased to an ounce and a half, 
and the water increased in proportion. The treatments should be given 
two or three times weekly. When the intestine is chafed and irritable 
and tends to bleed, Gant has the patients use, on the remaining days, 
enemata of an emulsion composed of olive oil, 2 ounces, and sub- 
nitrate of bismuth, half a drachm, or nitrate of silver 60 grains, to 
the pint. When the inflammation is caused by threadworms it can be 
quickly subdued by a few copious injections of salt or limewater; 
santonin may be administered if the case justifies it. When due to 
gonorrhceal virus, frequent irrigation of the bowel with hot water or 
bichloride, 1 to 6,000, as hot as it can be borne, will be followed by 
gratifying results. In a general way, the treatment consists in keeping 
the bowels open and correcting errors in diet, together with frequent 
hot and cold irrigations. 

Periproctitis; Ischiorectal Abscess. — Frequently, an inflammation 
starting in the mucous membrane extends through the rectal wall into 
the loose tissues around it, causing a diffused or circumscribed peri- 
proctitis resulting in ischiorectal abscess. Gant is of the opinion that 
this condition is made possible through the intestinal bacteria (probably 
the colon bacillus) having pyogenic properties, escaping into the blood 
vessels or lymphatics as a result of erosion of the mucous membrane. 
Another evidence of this is the fact that the pus from nearly all, if not 
all, ischiorectal abscesses contains the colon bacillus in large num- 
bers. In addition to the symptoms of a simple inflammation of the 
rectum, we now have those of a constitutional character, as a chill, 
high temperature, quick pulse, restlessness, and in fact all the phe- 
nomena of pus formation. Circumrectal inflammation may be caused 
by an operation with resulting infection, or by the breaking down of 
tuberculous deposits. 

Treatment. — Powell claims to abort ischiorectal abscess by deep in- 
jections of carbolic acid. Gant has not tried this plan, but has been in 
the habit of using the ordinary palliative measures until there is evi- 
dence of pus formation. He then opens the abscess by a free incision, 
breaks up all pockets with the finger, curettes out all gangrenous 
tissues, and then swabs out the cavity with carbolic acid and packs it 
witli sterile gauze. The dressings are removed whenever they are 
soiled; the wound is then irrigated and repacked loosely with gauze. 
Many physicians make the mistake of putting the dressings in too 
tightly, thereby arresting granulation. Patients should be told that 
they have a serious trouble which may result in fistula and a second 
operation, though this is rarely necessary when the abscess has been 
treated properly, and by that is meant radically. 

Gonorrhoea of the rectum is of occasional occurrence in America, 
but more frequent in England, and particularly in France. It is caused 
by infection of the rectum with the gonococcus of Neisser, although, 
as ordinarily found, it is here, as elsewhere, a mixed infection. It is 
generally caused by an associated attack of gonorrhoea infecting pri- 



INFECTIONS OP THE RECTUM 827 

inarily the genito-urinary apparatus. The discharge, which is generally 
copious in the acute stages, may bathe the perineum or invade the anal 
folds, from which it gains ready access to the mucous surfaces above 
the anal constriction. In other instances, and, perhaps, in the majority 
of all instances, the infection occurs as the result of using for the pur- 
pose of a rectal injection a syringe nozzle which has been employed in 
an infected vagina. The disease may result from perverted sexual 
indulgences. 

The pathology is essentially that of an acute inflammation depend- 
ing for its occurrence, primarily, upon the specific coccus of Neisser. 
The action of this micro-organism is very virulent and results speedily 
in the destruction of at least limited areas of rectal epithelium, result- 
ing in the development of granular patches which are ordinarily desig- 
nated ulcerations. The mucous follicles are invaded, resulting in their 
stimulation to catarrhal activity. If the epithelium of the efferent 
ducts is destroyed, they may become occluded, resulting in the develop- 
ment of retention cysts. The majority of the follicles, however, un- 
dergo hypertrophy and become more or less persistently catarrhal. In 
the presence of an infection atrium, the micro-organisms penetrate the 
deeper structures and may cause ischiorectal abscesses; or they may 
invade the lymph spaces causing enlargement of the pelvic lymphatics, 
or even resulting in some cases in suppuration. The infection may, by 
traversing the lymph channels, reach the peritoneum, causing septic 
inflammation of that membrane. When the inflammation has been so 
intense as to cause extensive epithelial destruction, post-inflammatory 
contractions resulting in stricture may supervene. 

The symptoms of gonorrhoea of the rectum consist in pain asso- 
ciated with burning and tenesmus in the earlier acute stages; there is 
also a copious muco-purulent secretion which is discharged at frequent 
intervals. The diagnosis depends upon the demonstration by means 
of the microscope of the gonococcus of Neisser. 

Treatment must be based upon the facts that the infection is a 
virulent one and that the surface of the rectum is very absorbent. 
Antiseptic agents, such as carbolic acid or the mercuric bichloride, are 
not eligible, while nitrate of silver is so destructive and so painful that 
it ought not to be employed. Strong injections of saturated solutions 
of boric acid, however, are well borne, and have pronounced antiseptic 
properties; to secure their best effects, however, they should be pre- 
ceded by copious injections of a detergent saline solution, such as 
the bicarbonate of sodium. If the injections are given cool, they will 
be better borne and have a soothing effect upon the inflamed rectum. 
It is well, in some cases, to begin the treatment by means of a saline 
cathartic, as the faecal current induced by that means will wash out 
much of the infection; and, besides, the Bacilli coli communes, which 
are brought down in large numbers, have a bactericidal action upon the 
gonococci. Topical treatment should be continued until the gonococci 
can no longer be demonstrated in the rectal secretions. 



828 A TEXT-BOOK OF GYNECOLOGY 

Syphilis of the Rectum. — Syphilis of the rectum is of frequent oc- 
currence, and may manifest itself at any stage and in a variety of forms. 
It is more common in women than men because of the proximity of 
the anus and vulva. The inoculation of the rectum may be the result 
of syphilitic discharges coming from the vagina dribbling over the 
anus; again it may be brought about by a chancre on the penis coming 
in contact with the anal aperture during sexual intercourse, and occa- 
sionally through unnatural copulation (paederasty). Chancroids will 
be considered along with syphilis because it is often difficult to distin- 
guish between the hard and soft sores, and, further, because the local 
treatment of these two affections is identical. Syphilis may reveal itself 
at the intestinal extremity in the congenital variety or in the form of 
a chancre, chancroid, mucous patch, condylomata or gummatous de- 
posit. 

In congenital syphilis of the rectum, the anus and vulva will be 
disfigured by multiple mucous patches and irritating fissures, which 
cause the child much pain when a hard stool is passed. Such children 
have notched teeth and the usual characteristic markings of inherited 
syphilis. 

True chancre of the rectum is uncommon, but, when present, its 
appearance does not differ greatly from that of chancre elsewhere. 
There is but one ulcer, surrounded by a hard, raised, inflammatory band, 
which is not very sensitive to the touch, and does not give much pain 
unless irritated. It is sometimes quite difficult to distinguish between 
it and a chronic fissure or ulcer, and for that reason we should not 
be hasty in making our diagnosis, but should wait for the eruption 
which will certainly settle the question. 

Chancroids at the anal margin are quite common, especially in pros- 
titutes, but cause more suffering than when located on the penis or 
vulva, which fact is attributable to the irritation caused by the passing 
over them of the faeces. They are usually multiple, superficial, and 
have sharply defined edges, are sensitive to the touch, and give off a 
discharge which irritates the skin, causing a pruritus that is difficult to 
relieve. Now and then they extend up the rectum and, when healed, a 
sufficient amount of contraction follows to produce a stricture. They 
are occasionally seen to become phagedenic and rapidly eat their way 
into adjoining structures, entirely destroying the external sphincter 
in less than a week's time. 

Mucous patches are disposed to form at the anal margin during the 
second stage of syphilis. They are moist, slightly elevated, and give 
off a foul odour, are grayish in colour, and are found more frequently 
in this locality than, perhaps, any other manifestation of this disease. 
"When the parts are not kept clean, they multiply swiftly and coalesce, 
forming thick warty masses, called condylomata (Fig. 339), and are 
covered with an offensive discharge that soon inoculates the neigh- 
bouring skin and membrane; in fact, if allowed to run an uninterrupted 
course, they may attain enormous proportions. At times, these masses 



INFECTIONS OF THE RECTUM 



829 



will be separated by deep fissures, in other cases they degenerate into 
a low form of ulceration. 

Gummed a are not seen especially frequently, even by those physi- 
cians who do a large practice in rectal surgery; at the same time they 
are to be found in the rectum more often than is generally believed 
by the profession, and with 
greater frequency in this lo- 
cality than elsewhere in the 
intestine. When detected early 
in their formation, they give 
to the finger a sensation simi- 
lar to that of an abscess before 
fluctuation is present; in other 
words, they feel like thick, 
flat, indurated masses in the 
rectal wall. After they break 
down, the rectum feels ragged 
to the touch because of the 
nodules and intervening ul- 
ceration. As a rule, healing 
occurs as the mass gives way, 
and the ulceration extends un- 
til sufficient contractile tissue 
is formed to make a tight 
stricture. Gummata are rare- 
ly numerous and large enough 
to obstruct the calibre of the 
bowel to any serious extent. 
Neither do they cause a great 
deal of pain by pressure upon 
the nerves. On the other 
hand, when a stricture has 
followed their breaking down, 

the suffering of such patients is pitiable to behold, they spend most 
of their time in the closet without relief, have local and reflected pains, 
itching about the anus, pass large quantities of pus, blood, and mucus, 
and frequently suffer from abscess, fistula, and, occasionally, incon- 
tinence. 

Treatment. — Infants suffering from congenital syphilis must be 
put through a course of treatment early in their career, if we would 
rid them of this terrible inheritance. The treatment should not be 
confined to the child alone, the mother should be given the usual anti- 
syphilitic remedies during the nursing period. She should take ten 
grains of the iodide of potassium three times daily, a short time before 
the baby is permitted to be nursed. In addition, if she is run down, 
tonics should be given to build her up. The child should be given 
small doses of mercury, preferably in the form of an ointment rubbed 




Fig. 339. — " They multiply swiftly and coalesce, 
forming thick warty masses.'" — Gant (page 828). 



^ 



830 A TEXT-BOOK OF GYNECOLOGY 

in over the abdomen or soles of the feet. For the local manifestations 
about the anus, cleanliness is the principal thing. To encourage heal- 
ing, solutions of alum, zinc, lead, or the bichloride of mercury, or pow- 
ders such as calomel, iodoform, orthoform, subiodide of bismuth, or 
tannic acid, judiciously applied, will render efficient service. 

In chancres and chancroids, persons suffering from the former 
should be put through the ordinary antisyphilitic treatment. The local 
treatment for the soft and hard sores is practically the same. They 
should be cleansed several times a day with antiseptic and stimulating 
solutions, and covered with a reliable ointment or powder known to 
have healing powers. Sometimes it becomes necessary to make strong 
applications to them of the nitrate of silver, carbolic or nitric acid, or 
perhaps the actual cautery; the latter is especially valuable where they 
take on a phagedenic character. 

When they are seen in the early stage, mucous patches require 
the same treatment as the chancre; but later on, when they have pro- 
liferated and formed numerous condylomatous masses upon both the 
skin and mucous membrane, they require radical measures. Gant 
excises them with the scissors and thoroughly cauterizes their base with 
the Pacquelin cautery, and then treats them in the same manner as 
traumatic ulceration. They are so persistent that even this operation 
may have to be repeated. 

Gummata require both constitutional and local treatment. The 
iodide of potassium in large doses seems to prevent the formation of 
new deposits and to hasten the absorption of those present, when 
accompanied by massage of the rectum by means of the Wales rectal 
bougie. Stricture following their breaking down should be treated as a 
stricture from other causes similarly located (see Stricture of the 
Rectum). 

Tuberculosis of the Rectum. — The rectum, like other organs of the 
body, is occasionally the seat of tuberculosis; here, however, suffering 
is greater and healing more difficult to obtain because of the function 
of this organ. It is interesting to note the proportion of persons suffer- 
ing from phthisis who are subjects of anal fistula and the number of 
the latter who are phthisical. Probably " from 4 to 6 per cent of all 
phthisical patients have fistula, while a much larger percentage of 
those afflicted with fistula have phthisis — 12 to 15 per cent." Koch 
holds that tuberculosis of the intestine may be primary, or secondary 
to pulmonary involvement. The bacilli may be introduced in food, 
especially milk, or through the swallowing of sputum coming from a 
tuberculous lung. In perfect health, tubercle bacilli are destroyed by 
the gastric juice, but in cases of phthisis where there is a lowered 
vitality and a weakened gastric fluid, it is believed that they pass 
through the stomach into the intestine without losing their activity. 
Earle maintains " that the tuberculous process in mucous membranes, 
as well as in the lungs, can advance independently of the formation of 
miliary tubercles." He also reports 3 cases of primary tuberculosis, all 



INFECTIONS OF THE RECTUM 831 

in negroes. He says, " What was particularly striking, was the apparent 
acuteness of the process; the mucous membrane between the points 
of ulceration was swollen and injected; in some cases covered with a 
slight fibrinous exudation. The ulcers appeared to result from the 
simple breaking down of this swollen and injected mucous membrane." 
Gant has never observed the condition just described. On the con- 
trary he has often seen tuberculous ulceration of the rectum where 
the mucous membrane was thin, pale, and covered with a thin rice- 
coloured discharge. 

Tuberculosis manifests itself in and near the rectum in three dif- 
ferent forms, viz., ulceration, stricture, and fistula. 

Ulceration. — From a clinical standpoint there are two kinds of 
tuberculous ulceration about the rectum, neither of which is of com- 
mon occurrence, but both are difficult to cure. One is a real tuber- 
culosis and can be demonstrated by the presence of the little tubercles 
and the bacilli. The second is a simple ulceration, from whatever cause, 
which is persistent owing to the debilitated condition of the patient 
caused by tuberculosis in the lung. 

In many cases of tuberculosis of the rectum, the disease is not con- 
fined to this organ, but distributes itself along the entire intestinal 
tract, and the breaking down of the deposit in one locality is followed 
shortly by a similar process in other parts, until the field of ulceration 
covers a considerable portion of the gut. In such cases, the prog- 
nosis is bad; on the other hand, when the disease is located in the 
anal region, we stand a fair chance of effecting a radical cure, if we 
resort to heroic measures. 

Tuberculous stricture is a rare disease in the rectum because the 
tendency of ulceration is to extend rather than to heal and form con- 
tractile tissue. Gant has observed in young women 2 cases of tight stric- 
ture undoubtedly of tuberculous origin. There are also two kinds of 
tuberculous fistulw, the one the result of tuberculous infection, and the 
other due to ordinary causes, but made more difficult to combat because 
of the run-down condition of the patient, occasioned by tuberculosis 
in other organs. 

Symptoms. — The general appearance of patients suffering from the 
different forms of tuberculosis of the rectum is about the same. They 
are usually much debilitated, have a sallow complexion, pinched face, 
sunken cheeks, prominent ears, clubbed nails, absence of fat in the 
ischiorectal fossa, and patulous anus surrounded by abundant long 
silky hairs. Many have an ugly cough and occasional hemorrhages, 
and are bothered with annoying night sweats. An ulceration, fistula, 
or stricture of tuberculous origin, bleeds less and is freer from pain than 
a similar condition from other causes. The mucous membrane is pale 
and thin, and the discharge from the diseased area is profuse, watery, 
and rice-coloured. Fistulous openings, instead of being small as in 
the ordinary fistula, are large, irregular in shape, bluish around the 
edges, and droop into the opening because of the undermined skin. 






832 A TEXT-BOOK OF GYNECOLOGY 

A probe can be inserted along the sinus without pain or difficulty. 
Those accustomed to treating rectal diseases have little trouble in 
distinguishing between the ordinary and the tuberculous types of 
fistula. 

Treatment. — In spite of our best efforts, a good percentage of per- 
sons afflicted with tuberculosis of the rectum will die in from six 
months to three years. The results of treatment are not so good in 
this ]ocality, because the disease is being constantly aggravated by the 
passage over it of faeces. The most essential thing in the treatment 
is to see that these sufferers get a reasonable amount of exercise in 
the sunshine, and are not confined in bed in a dark room. In fact, 
we should make everything about them as cheerful as possible. Every 
means should be resorted to, to build them up; generally, for this pur- 
pose, there is nothing better than plenty of nourishing food, stimulants, 
and tonics, such as creosote, guaiacol, cod-liver oil, malt extracts, iron 
occasionally, and, in fact, any tissue builder. If they can afford it, 
nothing will do them more good than a trip to the seaside or a change 
of altitude. Intestinal antiseptics should be given, as they sometimes 
benefit these patients very much; at other times, however, they are 
worthless. Ulceration rarely yields to palliative treatment, though we 
have to rely on it now and then when operation is refused. The ulcers 
should be cleansed frequently, after which some stimulating or anti- 
septic solution or powder should be applied. If they have a tendency 
to spread, a thorough burning with nitric or carbolic acid becomes 
necessary. When the treatment of tuberculosis is left entirely in Grant's 
hands, he treats it as though it was malignant. He curettes and trims 
the edges of the ulcers; after this, the affected area is thoroughly cau- 
terized with a Pacquelin cautery. The post-operative treatment is the 
same as for a granulating wound of the rectum from other causes. Tu- 
berculous fistula? should be laid open and all diseased tissue removed, 
and should then be cauterized as though it were an ulceration. Care 
should be used not to sever the sphincter more than once, for incon- 
tinence occasionally follows the operation. If it is thought best not 
to give a general anaesthetic, to lose much blood, or to put the patient 
to bed, a ligature may be passed through the sinus and brought out 
at the anus, where it is tied and allowed to cut its way out. A cure will 
sometimes follow this method. Tuberculous stricture requires prac- 
tically the same treatment as a constriction in the rectum from other 
causes. In the majority of cases, however, nothing short of colostomy 
and the prevention of faecal irritation will do any good. After this 
operation a radical improvement will follow. 

Surgical conditions resulting from infections of the rectum are 
various. Those which will be considered in this connection are (a) 
anal ulcer or fissure; (b) ulceration of the rectum; (c) fistula; (d) 
stricture. 

Anal Ulcer or Fissure. — Salient Symptoms. — Often, there is itching 
at the anus. Pain on defecation or immediately thereafter is charac- 



INFECTIONS OF THE RECTUM 833 

teristic. Intolerably painful anal spasm is often present. This dis- 
ease sometimes affords a multiplicity of reflected symptoms. 

Diagnosis. — Anoscopy reveals a narrow gray or red erosion or 
ulceration lying between the pilasters. Careful and systematic digi- 
tal eversion of the anal folds, at the time when the patient bears 
down, may disclose the lesion. When the point of the probe comes in 
contact with the fissure, the patient usually signifies that the lesion 
is discovered. Fissures are most commonly situated posteriorly but 
may be situated at any point in the anal circumference. 

A hypertrophied bit of tissue of a pale gray colour, and of about 
the size of a pin head, is often noticeable at the lower end of the fis- 
sure; this is the thickened wall of the anal pocket, to which Ball has 
given the name of sentinel pile. 

Treatment. — The ulcer, if superficial, is to be touched with caustic 
or the electric cautery. This treatment is to be repeated after inter- 
vals of several days. It may be alternated with, or replaced by, the 
application of ointment, stimulating or sedative according to the re- 
quirements of the ulcer. A convenient method of applying the oint- 
ment is shown in the obturator-applicator (Fig. 327). 

This may be done by placing the ointment in the cup, as shown 
in the illustration, lubricating the distal end of the instrument with 
the ointment, and introducing the anoscope to the necessary depth. 
This manoeuvre places the ointment at a point opposite the diseased 
area where the obturator is to be steadied while the anoscope is 
drawn off it. The anus clasps the applicator around the anointed 
neck. Gentle rotation and withdrawal of the instrument expands the 
anus and exposes the otherwise infolded and concealed diseased area, 
and rubs into its surface the medicament which the grasping anus 
completely strips from the obturator. Application of nitrate of silver 
solution is efficacious. 

The simplest and most efficacious treatment in that form of fissure 
that undermines the integument at its inferior end, consists in splitting 
the pocket by means of a small scalpel under infiltration anaesthesia 
by means of eucaine or nirvanine solution. The hypertrophied tissue 
should be trimmed away. The ulcer should then be touched with a 
solution of nitrate of silver, 40 grains to the ounce, and an opium sup- 
pository introduced. The anus should be subsequently dilated twice 
daily and the wound kept open till perfectly healed. Semidaily im- 
mersion of the hips in hot water should be practised. The conven- 
tional operation for fissure which requires general anaesthesia, divul- 
sion of the sphincters, and their division by incision, is haphazard 
surgery and not uniformly curative, mutilates an important organ, 
is hazardous to its functions, and, in a measure, dangerous to the life 
of the patient. 

Ulceration of the Rectum. — Salient Symptoms. — There is usually 
steady aching or sensation of heat and weight in the sacral region 
and lumbar spine ; the disease is initiated with a short period of obsti- 
54 



834 



A TEXT-BOOK OF GYNECOLOGY 



pation or constipation, sometimes followed by a somewhat longer 
period of diarrhoea ; finally, there are discharges of mucus. The 
faeces are sometimes streaked with mucus, with patches of membrane, 
and with specks of blood, and there is always more or less purulent 
material discernible. Pain and soreness are not uniformly present 
when the disease is situated high up in the rectum, but are invariably 
present when it is situated near or at the anus. 

Diagnosis. — Proctoscopy reveals the fact that the mucous mem- 
brane lining the rectal chambers is deeply injected. The arborescent 
arterioles may appear in clusters of bright red twigs. The club-shaped 
venous radicles, which are of a purple colour, may be observed some- 
what elevated above the surface of the mucous membrane at various 
points throughout the chambers, and there is a generally diffused red- 
ness throughout the entire area involved. Extensive proctitis some- 
times prevents inflation of the rectum. This may be overcome by 
spraying the rectum with a 4-per-cent solution of cocaine, which 
causes an ischaamia, thins the wall of the organ, and renders it inflat- 
able or dilatable by the use of the coactor. The ulceration is charac- 
terized by the destruction of a circumscribed area of epithelium occu- 
pied by reddish granulation tissue; the surface is often seen coated 
with inspissated muco-pus. Ulceration may be accompanied by a 
more or less diffused chronic proctitis with general superficial erosion 
of the mucous membrane. Venereal ulcers present their typical fea- 
tures when situated in this organ. Tuberculous ulceration presents 
a clearly defined border and is usually surrounded by a pale blue 
mucous membrane. Microscopic examination of scrapings positively 
determines its character. 

Treatment. — Inflammation and ulcerations of the rectal mucous 
membrane may be rapidly cured by spraying the part with silver- 
nitrate solutions of 3 or 
4 grains to the ounce. 
With the patient under 
proctoscopic examination, 
the operator should take 
the proctoscope in his left 
hand, and in his right, 
the anal atomizer which 
should be attached to a 
compressed-air reservoir. 
By co-ordinate movement 
of the hands, each of 
the chambers involved in 
the disease may be rap- 
idly and systematically 
sprayed with the solution (Fig. 340). If the hand-bulb spray is used, an 
assistant will be required to hold and direct the proctoscope from 
chamber to chamber. 




Fig. 340. — "Each of the chambers involved in the dis 
ease may be rapidly and systematically sprayed. "— 
Martin. 



INFECTIONS OF THE RECTUM 835 

Because of the humidity of the rectum, the actual cautery should 
not be introduced into it as the consequent rapid evaporation occa- 
sions intense pain. Chancroid ulcers should be coated once with the 
charcoal-and-sulphuric-acid paste. Enemas of bovinine prove decid- 
edly reparative. Rectal lavage should be employed daily. 

Fistula. — Salient Symptoms. — Muco-purulent discharges from the 
rectum, or sero-purulent discharges from an opening in the adjacent 
anal surface, are the common manifestations of this disease. 

Diagnosis. — With the patient in the Sims posture, manual eversion 
of the buttocks should be practised while the patient is required to 
bear down. At this moment, ocular inspection of the field should 
be made. Crypts, lacunae, or other depressions of the surface, should 
be critically examined with the point of the probe. Should the 
probe enter, the patient should be required to relax the parts, and 
a tentative search should be made for the internal orifice of the fis- 
tula. The probe should be steadied and the patient put into Martin's 
posture, which usualty smooths out the intra-anal folds of membrane, 
and the anoscope introduced, and, by means of another probe, in- 
spection should then be made of the mucous surface of the anus to 
determine if there is an internal orifice. The internal orifice of a 
fistula discharging internally is usually marked by small granulations 
or vegetations. The search may be made more thorough if a small 
applicator is employed to smooth out intra-anal folds of mucous mem- 
brane. The sphincters should be cocainized and a fenestrated conoid 
speculum, such as. Aloe's, inserted on its obturator, and the obturator 
or slide withdrawn. This instrument should be introduced with its 
fenestrum straddling the tissues penetrated by the first probe. Care- 
ful search for an internal orifice should be repeated. If none is dis- 
covered, the probe should be withdrawn and the cavity of the fistula 
injected, at its external orifice, with a sterile solution of milk or per- 
oxide of hydrogen and the anoscopy repeated. If even this manip- 
ulation fails to discover an internal orifice, further search should be 
abandoned till the time of operation. 

Treatment. — The probe should be introduced into the external 
orifice of the fistula, the conoid speculum reintroduced, and its fenes- 
trum made to straddle the probe as already described. The tissue 
from the external orifice of the fistula to a point within the anus as 
high as the distal end of the probe, should be subjected to infiltration 
anaesthesia. The probe should be thrust onward through the mucous 
membrane and into the channel of the gut. An incision should be 
made through both mucous and cutaneous surfaces down to the probe. 
If, on the other hand, the fistula has an internal, but no external open- 
ing, the probe should be bent to form a long hook-end and should be 
carried through the anoscope or Aloe's speculum, and into the in- 
ternal orifice. When it has been made to pass as deeply toward the 
cutaneous surface as possible, the anoscope should be withdrawn and 
an effort made to draw the probe-hook deeper through the relaxed 



i 



836 A TEXT-BOOK OF GYNECOLOGY 

tissues and toward the skin. The probe should be steadily maintained 
in this position while the fenestrated conoid speculum is made to 
straddle it. Infiltration anaesthesia should be established, and an 
incision made in the manner already described. The wound should be 
antiseptically dressed and cared for. The more radical operation, con- 
sisting in dissecting out the sac and suturing together the freshened 
surfaces of the walls of the fistula, may be performed under local 
anaesthesia. This operation begins where the simpler procedure just 
described leaves off, inasmuch as that technique is necessary to expose 
the fibrous structure of the fistula wall. Bleeding vessels should be 
clamped and hot gauze pads applied to the wound till all hemorrhage 
is checked, for a bloodless field is necessary for infiltration anaes- 
thesia. The hemorrhage stopped, the anaesthetic solution should be 
injected all about the fibrous tissue to be removed, the most accessible 
portions should be seized with a hemostat for convenience of manipu- 
lation, and a rapid dissection made. An assistant must follow each 
sweep of the knife with the hot gauze, for anaesthesia and a non- 
bleeding field go hand in hand. The fibrous tissue should not be re- 
moved piecemeal; the portion dissected loose may be used as a re- 
tractor to facilitate the dissection of that still attached. The parts, 
fascia, sphincter and other muscle, and integuments, should be re-an- 
aesthetized and the wound closed by suture. Fistulae located laterally 
and anteriorly to the anus, and having an external orifice, if the recto- 
vaginal septum is not divided, take a course forward into the labium 
majus, or backward toward the anterolateral anal quadrants, which 
they tend to enter between the sphincters. Fistulae situated in the 
ischiorectal fossae usually penetrate the rectum on the side of their 
origin and between the sphincters. If they enter the body farther, 
they generally take an outward direction beneath the levator ani or 
coccygeus muscle. External fistulae are not often situated posteriorly. 
But, not infrequently, a complete internal fistula may be discovered 
by means of the diagnostic technique described, situated posteriorly, 
and having an inferior orifice at the border of the internal sphincter 
and a superior orifice posteriorly and above the coccygeo-levator ani. 
When the probe has entered an inch (2.54 centimetres) or more, a 
fenestrated curette should be introduced into the rectum to a point 







Fig. 341.— The valvotome.— Martin (page 837). 



higher than the estimated site of the end of the probe, and an endeav- 
our made to hang the curette thereon. If this succeeds, and the 
curette can not be directly withdrawn, the diagnosis of the complete 



INFECTIONS OF THE RECTUM 



837 



fistula just described is made. A grooved director should be substi- 
tuted for the probe, a 3-inch needle fixed to the hypodermic syringe, 
and the tissue between the director and the rectal lumen infiltrated 
with the anaesthetic; then the special knife shown in Fig. 341 may 
be put into the director and 
made to cut through the ano- 
rectal wall. When this is ac- 
complished, the director and 
curette may be withdrawn 
without removing the former 
from the fenestrum of the lat- 
ter. The fibrous base of the 
fistula should now be curetted 
and subsequently packed. 
Daily anal dilatation should 
be enjoined till the wound 
heals. Simple external fis- 
tula? of recent origin may be 
cured by curettage, by injec- 
tion of stimulating fluids, and 
by vigilant general care. 

Abscesses and fistula? in 
the pelvic floor about the 
anus, often present the most 
complex problems. Their per- 
fect comprehension involves 
a study of the fascia? of the 
pelvic floor. 

Stricture of the rectum is 
a diminution of the calibre of 
the bowel from any cause. 
Usually it is the result of an 
ulceration leaving thickened 
walls of contractile tissue 
(Fig. 34,2). Tumours within 
or without the bowel are often 
responsible for this affection; fig. 34-2.- 
again, it may be the result of 
an enlarged prostate, or of the 

pressing of the rectum back upon the bony structures by a retroverted 
uterus. In exceptional cases, it is due to fibrous bands extending from 
one side of the bowel to the other. From the standpoint of physical 
exploration, strictures may be divided into three classes: viz., (a) annu- 
lar or narrow; (b) tubular or broad, and (c) nodular. In the first, only a 
small portion of the bowel is involved ; in the second, the strictured 
area may occupy several inches; while in the third, the obstruction 
is the result of one or more nodular tumours projecting into the 




Ulceration leaving thickened walls of 
contractile tissue." — Gaxt. 



838 A TEXT-BOOK OF GYNECOLOGY 

calibre of the bowel at one or more points. Again, strictures are 
further divided, and are called complete when there is total obstruction, 
and incomplete when all or a part of the faeces escape through them. 
Congenital strictures will not be dealt with here. From a pathological 
standpoint, Gant classifies strictures of the rectum as follows: 

(1) Traumatic; (2) syphilitic; (3) tuberculous; (4) catarrhal; 
(5) dysenteric; (6) malignant. 

(1) Traumatic. — All agree that traumatism is a frequent cause of 
stricture of the rectum. It may be the result of any one of a number 
of operations performed about the rectum and anus for the relief of 
hemorrhoids, fissure, ulceration, fistula, prolapse, or cancer. It is 
sometimes caused by direct injury to the rectum as the result of an 
accident, or the swallowing of some hard substance, as a piece of bone 
or a pin, which lodges near the anus and keeps up a constant irrita- 
tion. The most frequent cause of traumatic stricture is constipation 
and impaction. Chronic constipation, where the faeces are allowed to 
remain in the bowel for several days at a time, is a frequent cause 
of stricture. (2) Syphilis may be the cause of stricture of the rectum 
as a result of chancres or chancroidal ulceration in the initial stage, 
of gummatous deposits, or of extensive ulceration following the break- 
ing down of such deposits, the latter being by far the more frequent 
cause. Syphilis probably causes as many strictures as all the other 
etiological factors put together. (3) Tuberculosis of the rectum sel- 
dom causes stricture, because, when the tubercles begin to give way, 
they can only exceptionally be successfully healed, in consequence 
of the absence of contractile tissue. Gant has seen cases of marked 
constriction, however, that could not be attributed to other causes. 
(4) Chronic catarrhal inflammation of the rectum may result in stric- 
ture as the result of occlusion brought about by the inflammatory 
thickening of the bowel, or from an ulceration started and maintained 
by the presence of large quantities of irritating mucus. (5) Dysen- 
teric stricture is rarely seen in this section of the country, because 
here we have dysentery only in a mild form, but in tropical countries, 
where it is common in the severe form, it frequently results in a light 
stricture. (6) Stricture due to cancer is found as often in the rec- 
tum, as in all other parts of the intestines. It may be the result of 
one or more large hard masses obstructing the calibre of the bowel, 
or be due to cicatrization following ulcerations when they break down, 
or to both these causes. 

The symptoms of stricture may be local or constitutional, depend- 
ent upon the condition at the time of observation; if extensive ulcera- 
tion is present and the obstruction is complete, the usual symptoms 
of the accumulation of pus and obstruction will be present. The 
symptoms usually met with in a bad case of stricture are, constipation at 
the beginning; diarrhoea, intermitting with constipation; intense 
straining; a sensation as though the bowel never completely emptied 
itself; slight rise in temperature; occasional chill; indigestion; mild 



INFECTIONS OF THE RECTUM 



839 



peritonitis; tympanites; usually loss in weight; incontinence; dis- 
charges of pus, blood and mucus; pain in the rectum and distant 
parts ; change in size and character of the faeces ; numerous long slen- 
der skin tags, and partial or complete obstruction. 

Diagnosis. — A large majority of rectal strictures are located in the 
lower 3 inches of the bowel and are easily recognised. When in the 
upper part, if they can not be located by the aid of bougies and the 
colon tube, an anaesthetic should be given, the abdomen opened, and 
the gut pulled up and examined. 

Treatment. — The treatment is (a) palliative, and (b) operative. 
(a) Palliative measures for the relief of stricture consist in keeping 
the stricture open and hastening absorption; softening the faeces that 
they may pass through it : alleviating pain, and protecting the system 
against the absorption of poisons contained in the rectum because 
of the pus and retained faeces. Iodide of potassium in increasing 
doses and the massage of the stricture with the fingers or soft bougies, 
do a great deal of good in the 
earlier stages; but when the 
constriction is composed of 
contractile tissue the results 
are not so good. The diet 
should be restricted, so far as 
possible, to fluid and semi- 
solid foods, and to those 
which leave little residue. 
Pain is best alleviated by 
keeping the rectum clean 
with astringent, stimulating, 
or antiseptic solutions; when 
faecal masses accumulate 
above the stricture, mild 
laxatives should be used, and 
high enemata of water, soap- 
suds, or oil and glycerine, but 
strong purgatives should 
never be given. In order 
that the patient may get 
some rest at night, opium, 
morphine, chloral, or the 
bromides, intelligently ad- 
ministered, will do as well as 




Fig. 348. — " The calibre of a stricture may be ma- 
terially increased by means of gradual . . 
divulsion. 1 '— Gant ( page 840). 



any other drugs; but tliev must be 



ith caution, for this affec- 



tion is chronic, and many of these sufferers readily fall into the habit 
of taking them to ease their pain. 

(b) Operative. — In spite of the best palliative treatment, most stric- 
tures gradually progress until partial or complete obstruction is pres- 
ent, and it is necessary to resort to an operation to give them tempo- 



§40 A TEXT-BOOK OF GYNECOLOGY 

rary or permanent relief. Enthusiasts in the use of electricity main- 
tain, that, by this means, they can destroy the stricture or cause it to be 
absorbed. Grant, however, from what he has seen, is inclined to doubt 
the accuracy of this claim. 

The following are the most favoured surgical procedures for the 
relief of stricture of the rectum, viz. : 1, dilatation ; 2, internal proc- 
totomy; 3, external proctotomy; 4, excision; 5, colostomy. 

The calibre of a stricture may be materially increased by means of 
gradual (Fig. 343) or forcible divulsion. The first is accomplished 
gradually by the passage of graduated soft-rubber bougies; steel in- 
struments should not be used because of the danger of rupturing the 
bowel. Bougies should be used two or three times each week until 
relief is obtained. If the patient will give her consent, forcible divul- 
sion is preferable, because, under general anaesthesia, we can accom- 
plish with the fingers in five minutes what would otherwise take 
weeks. Strictures of more than 3J inches should not be divulsed un- 
less every precaution has been taken, for if the bowel is ruptured, the 
rectal contents are dumped into the peritoneal cavity and death will 
shortly result. 

Internal proctotomy is done by guiding a blunt-pointed bistoury 
with the index finger until it is above the point of constriction, when 
the latter is severed at one or more points as the case demands. A 
piece of gauze is then placed in the incisions, to be changed from time 
to time, and the rectum cleansed as after any other wound in it. 

External (or complete) proctotomy is performed by carrying the 
knife above the stricture, as in the internal method; it is then pointed 
backward until the bony structures are reached, when it is brought 
down and out, dividing the stricture and other tissues including both 
sphincters, thus leaving a long, deep, triangular cut. The advantages 
of this operation over the one just described, are several; it permits 
of free drainage, bleeding can easily be detected and arrested, it 
allows the free exit of accumulated faeces, and admits of medication, 
at all times, both below and above the strictured area. When a stric- 
ture involves only the superficial structures of the rectum, is freely 
movable, and is situated near the anus, excision is justifiable. When 
ulceration is extensive and obstruction is threatened, colostomy should 
be insisted upon, for it is the only thing that offers any permanent 
relief from the never-ending desire to stool. Frequently, after this 
operation, patients gain flesh and return to their work feeling like 
new beings. This operation is described in the chapter on Malignant 
Growths of the Eectum. 



CHAPTER LII 

NEOPLASMS OF THE RECTUM AND ANUS 

Adenoma — Lipoma — Fibroma — Papilloma — Angeioma — Teratoma (dermoid cysts) 
— Retention cysts — Myoma and enchondroma — Malignant growths, symptoms, 
treatment — Operations: Divulsion; internal proctotomy; posterior proctot- 
omy; curettage; colostomy; excision — Hemorrhoids, causes: External, symp- 
toms, treatment: Internal, symptoms, treatment — Operations: Injection; 
Whitehead's; ligature; clamp and cautery. 

The rectum and anus are the seat of new growths as frequently as 
other parts. Some writers labour under the mistaken idea that ma- 
lignant tumours and simple polypi are about the only neoplasms to 
be found in this locality. Gant does not deny that they are of fre- 
quent occurrence, but there are a variety of other growths which mani- 
fest themselves in the rectum with varying frequency. Any of the fol- 
lowing-named tumours are likely to be met with by physicians having 
a large rectal following: (1) adenoma (polypus); (2) lipoma; (3) 
fibroma; (4) papilloma: (5) angeioma: (6) teratoma (dermoid 
cysts) ; (7) retention cysts; (8) myoma: (9) enchondroma; (10) 
malignant growths; (11) varicose tumours (hemorrhoids). 

Adenoma (Polypus). — Adenomata are found more frequently in the 
rectum than in any other part of the intestinal canal. In fact they 
occur there with greater regularity than almost any other tumour. 
Benign or simple adenomata are common in childhood, and com- 
paratively rare in adults, unless preceded by some other disease with 
a coincident discharge. On the other hand, malignant adenomata usu- 
ally attack those past middle life, and are rarely seen in children. 
All rectal tumours have a tendency to become pedunculated, because 
they are dragged down daily by the faeces. The word polypus is com- 
monly applied to any growth in this locality having a narrow or 
pedunculated laminar attachment, with a large movable pendulous ex- 
tremity. Van Buren once said that "in proportion as a tumour becomes 
pedunculated its danger of being malignant lessens/' Gant's experi- 
ence has been in accord with Van Burens. Xevertheless. it is at times 
difficult to distinguish between the benign and malignant forms of 
adenoma. There are two kinds of polypi, the adenoid, or soft (Fig. 
344), and the fibrous, or hard (Fig. 345). In rare instances, either of 
these growths may be found in great numbers scattered over the en- 
tire rectal mucosa; they are then distinguished as disseminated polypi. 

841 



842 



A TEXT-BOOK OF GYNECOLOGY 



Symptoms. — Polypi vary in size from that of a pea to that of an 
English walnnt. The symptoms depend largely upon the size, loca- 
tion, number, and condition, of the tumours when seen. When situ- 
ated high up in the rectum or sigmoid, they manifest their presence 
by irritating the mucous membrane, causing a sensation of uneasiness 
and the discharge of considerable mucus. Occasionally, they cause 




Fig. 344. — " The adenoid or soft poiypus."- 
Gant (page 841). 



Fig. 345. — " The fibrous or hard polypus.' 
Gant (page 841). 



invagination, tenesmus, and straining. If ulcerated, they bleed, and, 
when located near the anus, they protrude during stool. As a rule, 
they cause little pain unless strangulated. 

Treatment. — Ordinary polypi are easily cured when within reach. 
They may be clamped with Gant's clamp, cut off, and the stump thor- 
oughly cauterized with the Pacquelin cautery. When a cautery is not 
available, ligature and excision will prove quite as effective, but will 
cause more pain. When small, they may be seized with forceps and 
twisted off; when high up in the rectum, the snare is sometimes serv- 
iceable; Gant prefers in such cases to seize the growth with a long- 
handled clamp forceps and allow it to remain in situ until it comes 
off of its own accord. Medication in these cases will prove unsatis- 
factory. Once in a while polypi come away spontaneously or are 
detached by feecal accumulations. 

Lipoma. — Fatty tumours are occasionally met with in the anal 
region and do not differ in their construction from that of similar 
tumours in other localities. Gant has seen them both in the circumrectal 
tissues and under the skin at the anal margin. One tumour on the 
buttock at the verge of the anus was quite as large as a goose's egg. 



NEOPLASMS OF THE RECTUM AND ANUS 



843 



Treatment. — The treatment consists in their enucleation and the 
closure of the wound with catgut. 

Fibroma. — In rare instances fibromata develop about the anus 
and vulva, and in the rectal wall, without becoming pedunculated. 
They then present themselves 
in the form of hard, smooth 
tumours (Fig. 346). They 
resemble fibromata of the 
cutaneous surface in every 
way, except that they are cov- 
ered by mucous membrane. 

Papilloma. — Papillomata 
are not uncommon in this re- 
gion because of the irritation 
of the parts by the faeces and 
infectious discharges coming 
from the vagina. Senn has 
frequently seen the rectum 
studded with papillary tu- 
mours varying in size from 
that of a hemp-seed to that 
of a cherry. They are to be 
seen on the skin about the 
anus just about as frequently 
as upon the mucous mem- 
brane. As before intimated, 
they may be the result of 
a syphilitic, chancroidal, or 
gonorrheal infection, or they 
may reveal themselves with- 
out any previous discoverable 
irritation. "When located in- 
side the rectum they are ac- 
companied b}^ occasional hemorrhages, the discharge of mucus, and 
tenesmus; when upon the skin, by smarting, soreness, and a foul odour 
when multiple and in clusters. 

Treatment. — Palliative measures are now and then effective. 
These consist in cleanliness, cauterization with acids, carbolic and 
nitric, or the application of astringent powders, as tannic and gallic 
acid, alum, zinc, or calomel. The radical method of cutting them off 
with scissors and cauterizing the stumps with the actual cautery is the 
most satisfactory way of dealing with them. 

Angeioma. — A few cases of angeioma (naevus) of the rectum have 
been recorded. Gant has never seen what he considers a typical case, 
though he has met with vascular growths which bled freely from vari- 
ous points. They were flat tumours, located about 2 inches above the 
anus. 




Fiff. 346. — " In rare instances fibromata develop 
about the anus and vulva and in the rectal 
wall.'" — Gant. 



844: A TEXT-BOOK OF GYNECOLOGY 

Treatment. — They should be extirpated by ligation or cut away 
with scissors, the bleeding being arrested with the Pacquelin cautery. 

Teratoma (Dermoid Cysts). — Dermoid cysts containing hair and 
sometimes teeth are not at all uncommon in the sacral region, and are 
frequently the exciting cause of fistula. Now and then they are found 
in the rectal wall and the hairs may be seen projecting into the rectum 
or out at the anus. They vary in size from that of a cherry to that of 
an apple. Their symptoms and management in this locality are the 
same as in other parts; the safest treatment is complete removal. 

Retention Cysts. — Retention cysts filled with secretions and excre- 
tions, which may or may not have undergone degeneration, are at times 
found in and outside the rectum. They occasionally reach enormous 
proportions, Gant having removed one 8 inches in circumference. In 
one case, they may be filled with firm sebaceous material, in another, 
with a fairly thick whitish fluid. They cause no discomfort further 
than a fulness of the part affected. 

Treatment. — The entire cyst wall should be carefully dissected out 
and the wound united with catgut, otherwise the cyst will refill. 

Myoma and Enchondroma. — New growths composed of muscular 
and cartilaginous structures have been found in the rectum. The 
former is of more frequent occurrence than the latter, and is found 
in that situation with greater frequency than in other parts of the 
intestine. Nothing short of removal should be considered for 
their relief. 

Malignant Growths. — There is still doubt as regards the true cause 
of malignant tumours. Statistics, however, show that they are on 
the increase in the rectum as well as in other organs. This does 
not apply to the negro race, as negroes are practically immune to this 
disease. Because of its function and make-up, the rectum is the seat 
of about 80 per cent of all morbid growths occurring in the intes- 
tines. Malignancy is common in middle life, less so in old age, and 
rarer still in childhood. The prognosis is, as a rule, bad, few living 
more than a year after the disease is recognised. In exceptional 
cases^ however, patients may live two, three, and even four years. The 
younger the person, the sooner death will ensue. Malignant growths 
of the rectum develop principally from glandular tissue, and are 
grouped by Cripps (Rectal Cancer, third edition, p. 56) under the one 
head of adenocarcinoma. Sarcoma is extremely rare in this region, but 
Grant operated on a case of fibrosarcoma with multiple fistulae involv- 
ing the rectum and anus (Fig. 347). Carcinomata may manifest 
themselves as flat tumours in the rectal wall, may project into the 
lumen of the bowel, or circumscribe the lumen by a nodular 
band. Because of this difference in their clinical appearance, Cooper 
and Edwards (Diseases of the Rectum, and Anus, p. 190) have de- 
scribed them as laminar, tuberous, and annular. Squamous-celled 
carcinoma (epithelioma) is occasionally met with at the mucocuta- 
neous margin. 



NEOPLASMS OF THE RECTUM AND ANUS 



8±5 



Symptoms. — In the earlier stages of rectal cancer, patients do not 
complain of acute pain, but of sensations of uneasiness, weight, and 
fulness in the bowel. When the tumour grows to considerable pro- 
portions and breaks down leaving a large ulcerated area, the following 
symptoms will be present : 

(1) Irregular or constant pains in the rectum, neighbouring or- 
gans, and back of and down the limbs; (2) typical cachectic waxy 
complexion; (3) tape or ribbonlike stools; (4) prolonged straining 
and a never-ending desire to empty the bowel; (5) abundant dis- 
charges of blood, pus, and mucus; (6) loss of flesh; (7) because of 
increased peristalsis, food is rushed through the alimentary canal un- 
digested; (8) constipation intermitting with diarrhoea; (9) low 




Fig. 347. — "A case of fibrosarcoma with multiple fistula? involving the rectum and anus." 

— Gant (page 844;. 



form of peritonitis ; (10) obstruction partial or complete ; (11) when 
the growth is located at the verge of the anus, pain is much more 
severe owing to sphincteric contraction; (12) in the majority of cases 
there is partial or complete incontinence. 

Treatment. — The treatment of malignant tumours of the rectum is 
unsatisfactory because most patients die in spite of anything that 
can be done. While Gant does not feel justified in stating that this 
disease is incurable, he does believe that total extirpation results more 
often in failure than its advocates would have the profession believe. 
Medication is useless beyond the relief it offers from pain, in the 
liquefaction of the fa?ces, and as a disinfectant in the various solu- 
tions used for irrigating purposes. The diet should be regulated and 
these sufferers should have plenty of sunshine and strengthening food. 



846 A TEXT-BOOK OF GYNECOLOGY 

Operations. — The following operations have been suggested for the 
relief of cancer of the rectum : ( 1 ) Divulsion, rapid, with the ringers, 
or gradual with bougies; (2) internal proctotomy; (3) posterior proc- 
totomy; (4) curettage and cauterization; (5) colostomy (Ailing- 
ham); (6) excision. The operations to be described should, with the 
exception of excision, be regarded as palliative measures only, and those 
who hope to make a radical cure with them will be disappointed. 

Divulsion. — Sometimes there are patients suffering from new 
growths at the anus and low down in the rectum, who are threatened 
with obstruction, and are constantly annoyed by straining in their 
endeavour to relieve the bowel, who yet refuse to let the knife be used. 
In such cases, it is justifiable to resort to stretching the rectum, either 
with the fingers or bougies as may be deemed best (Fig. 341), and 
temporary relief will follow, because the faeces escape and the rectum 
can be irrigated. 

Internal proctotomy consists in passing a probe-pointed bistoury 
beyond the point of constriction and incising the stricture or growth 
one, two, three, or as many times as becomes necessary, to relieve 
the obstruction. As a rule, the wound soon heals, contraction follows, 
and the operation requires to be repeated. 

Posterior proctotomy is, next to colostomy, the best of all the 
palliative operative procedures. It is performed as follows : Protect 
the knife with the finger and pass it well above the obstruction, then 
directly backward to the bony structures, and thence downward, carry- 
ing it through the rectum and sphincters, until the cut is on a level 
with the tip of the coccyx, thus making a long deep triangular wound 
that gives plenty of room for the escape of accumulated faeces and at 
the same time permits free drainage, a great advantage over the inter- 
nal method. Post-operative treatment consists in topical applications 
to the ulceration, and the occasional passage of a bougie to prevent 
rapid contraction. 

Curettage. — Persons suffering from that form of malignant growth 
in which numerous cauliflowerlike masses project into the rectum, 
inducing pain and the frequent discharge of pus and blood, can fre- 
quently be relieved by scraping them down to a level with the rectal 
wall, and then burning the raw surface thoroughly with the actual 
cautery. The operation should be repeated as soon as the growth 
returns. 

Colostomy is the most satisfactory measure we have for the relief 
of rectal cancer, and we do not except excision, taking one case with 
another. It diminishes the patient's suffering because it permits a 
free exit to the faecal matter above the diseased part, thereby doing 
away with the diarrhoea and straining. It permits free irrigation of 
the rectum. Many patients soon regain the flesh they had lost and, in 
fact, feel like new beings; and they are not constantly annoyed by the 
escape of faeces through the artificial anus as some writers have stated. 
The lumbar opening has been discarded for the inguinal (Fig. 348), 



NEOPLASMS OF THE RECTUM AND ANUS 



847 



principally because the patient can take care of herself after the latter. 
The most important point in the operation is to make a good spur, 
so that, when the gut external to the skin is removed, the ends of the 




Fig. 348. — u The lumbar opening has been discarded for the inguinal.' 1 — Gant (page 846). 

intestines will remain parallel, thus insuring that the faeces shall be 
deposited on the outside and not escape into the rectum as is the case 
when this precaution is not taken. A procidentia may ensue (Fig. 
349) when the 
mesentery is too 
long, in which 
case several 
inches of the in- 
testine should be 
cut off to prevent 
this accident. 

Excision. — 
Some writers af- 
firm that by ex- 
tirpation of the 
growth they can 
effect a perma- 
nent cure in a 
large percentage 

of their cases; such claims are just the opposite of the experience of 
those surgeons that confine their practice to diseases of the rectum. 
Gant does not say that life is not materially prolonged by this operation, 




Fig. 349. — " A procidentia may ensue." — Gaistt. 



848 



A TEXT-BOOK OF GYNECOLOGY 



but he does believe, however, that the patients radically cured in this 
way are few indeed; it has been his experience that the growth soon re- 
turns. Excision is all right in properly selected cases, but, in most in- 
stances, the surgeon does not see the patients until the disease is far 
advanced. A growth situated near the anus can usually be removed by 
making a posterior incision as far back as the coccyx. After the coccyx 
is removed, sufficient room will be obtained to enable the operator to 
free the rectum from its attachments, this being best done with the fin- 
ger or a pair of blunt scissors. The growth is then cut away, leaving the 
sphincter if possible, and the distal and proximal ends united; when 
there is too much tension, bleeding should be arrested and the bowel 
allowed to retract. If the peritoneum has been opened, it should be 
closed with catgut sutures or protected with sterile gauze and let alone. 
Bougies should be passed biweekly to prevent too much contraction. 
The high excision, or Kraska method, consists in removing a portion 
of the sacrum for additional room, and the suturing of the gut into 
the upper end of the wound when it can not be brought down and 
united to the severed gut below. The chief advantage claimed for this 
operation is that it gives sufficient room for the surgeon to remove the 




Fig. 350. — " Recurring adenocarcinoma about the sacral anus following Kraska 1 ! 
operation.'" — Gant. 



entire growth. However, Gant had a case of recurring adenocarcinoma 
about the sacral anus following Kraska's operation (Fig. 350). 

Hemorrhoids differ so widely in location, appearance, and make-up, 
that it is impossible to give a satisfactory definition of them. In a 
general way we might define them as being vascular tumours of the 
mucous membrane of the rectum, the anus, or both. They may be external 
or internal; the former are covered by integument, and the latter by 



NEOPLASMS OF THE RECTUM AND ANUS 



849 



mucous membrane. Tumours covered in part by skin and in part 
by membrane are known as combination piles. 

Causes. — The larger rectal veins pass through the rectal wall by 
means of little slits (Fig. 351). Verneuil believes the return flow of 
venous blood is impeded by the contraction of the muscular fibres 
around them, and, for this reason, he thinks that these little button- 
holes are an important factor 
in the causation of hemor- 
rhoids. We believe this to be 
in a measure true, but there 
are other factors that play a 
much more important part; 
because of gravitation, and 
the fact that the rectal veins 
have no valves, the erect pos- 
ture assumed by man has a 
great deal to do in the pro- 
duction of enlarged veins. 
Again the faeces, by the time 
they reach the rectum, are 
solid, and frequently cause 
venous obstruction. Certain 
obstructive diseases of the 
heart and liver, a retroverted 
uterus, stricture of the rectum 
or urethra, chronic diarrhoea, 
overpurgation, stone in the 
bladder, or anything that 
presses upon the veins, are 
causes ; frequent and pro- 
longed straining will, sooner 
or later, produce hemorrhoids. 
Many cases can be traced di- 
rectly to irregularities in liv- 




Fig. 351. — " The larger rectal veins pass through 
the rectal walls by means of little slits.' 1 — Gant. 



ing. In fact, anything that 

forces an abnormal amount of blood into the rectum, or interferes with 

its return therefrom, may be regarded as a cause. 

External Hemorrhoids. — There are two kinds of external piles; when 
composed of hypertrophied folds of skin, they are called cutaneous, 
when filled with a firm dark clot, thrombotic. The former are usually 
chronic and are the colour of the skin, the latter come on suddenly, 
have a bluish tint, and look like a bullet beneath the skin. 

Symptoms. — Under favourable circumstances they produce a sen- 
sation of fulness about the anus. When inflamed, a smarting is 
felt, and when relief is not to be had, the sphincter becomes irri- 
table and the suffering is materially increased by its frequent con- 
traction. 

55 



850 A TEXT-BOOK OF GYNECOLOGY 

Treatment. — In so far as the palliative treatment is concerned, both 
varieties of external piles should be treated alike. The diet should 
be restricted to fluids and semisolids, and if this does not suffice, a 
laxative should be given. For this Gant prefers Carabaha water, 2 
ounces in a tumbler of warm water before breakfast. The inflammation 
should be reduced by constant application of hot poultices, cold appli- 
cations, or lotions composed of lead, zinc, alum, opium, krameria, or 
other astringent remedies. When the suffering is sufficient to keep 
the patient awake, relief may be had by an injection of one fourth of 
a grain of morphine sulphate. To allay pain and soothe the sphincter 
muscle, the following ointment, which the patient may use freely both 
inside and outside the anus, may be given: 

I£ Morphinge sulphatis grana vj to viij ; 

Calomel grana xij; 

Vaseline gj. 

Sig. Use freely. 

An ointment composed of opium and belladonna is a good com- 
bination and will diminish pain. 

Surgical Treatment. — When the physician has the election of the 
method of treatment in a given case, he should not waste time with 
palliative measures, but should relieve the patient quickly and per- 
manently by operation, in one of two ways. The cutaneous pile should 
be cut off with the scissors and the edges of the wound brought to- 
gether with catgut or allowed to granulate. The thrombotic variety 
should be laid open with a bistoury, the clot turned out, the rent in 
the vessel cauterized, and the cavity packed with gauze, which prevents 
hemorrhage and allows the blood to escape in case bleeding occurs. A 
combination pile should be treated as the internal variety, except that 
the incision should be extended to include some of the adjoining skin. 

Internal Hemorrhoids. — There are two varieties of internal hemor- 
rhoids: capillary and venous. The former are supplied principally by 
the superficial vessels of the mucous membrane, and the latter by the 
veins of the mucous and submucous tissues. Capillary piles are broad 
flat tumours that bleed readily and look very much like strawberries. 
Venous piles are of frequent occurrence and are composed of dilated 
veins. They may be small, may remain within the bowel and bleed 
freely, or they may be large and protruding, and may bleed occasionally 
(Fig. 352). 

The symptoms of hemorrhoids vary according to the duration, kind, 
and violence of the attack. The following are some of the more com- 
mon symptoms subject to the above conditions: (1) Protrusion all or 
a part of the time. (2) Bleeding varying from a few drops to a pro- 
fuse hemorrhage. (3) A sensation in the rectum as if there was some- 
thing in the bowel that ought to come away. (4) Pain, intermittent 
and slight, or excruciating and constant, according to the amount of 
inflammation, ulceration and strangulation. (5) Spasmodic contrac- 



NEOPLASMS OP THE RECTUM AND ANUS 



851 



lion of the anal sphincters. (6) Extreme nervousness and loss of flesh. 
(?) When piles are ulcerated, there is more or less pruritus caused by 
the discharge. (8) When strangulation continues for several days, it 
causes constipation and a slight rise of the temperature. 

Treatment: Palliative. — Correct errors in diet, keep the faeces soft, 
and return all protruding tumours when seen before strangulation 
has begun, for once they are 
caught outside the anus no at- 
tempt at reduction should be 
made, because the irritable 
sphincter would immediately 
throw them out again. The 
remedies suggested in the treat- 
ment of external hemorrhoids 
for the relief of pain and in- 
flammation can be successfully 
employed in the treatment of 
internal hemorrhoids. When 
there is bleeding, it becomes 
necessary to inject astringent 
solutions into the rectum and, 
by means of a speculum, to 
apply styptics directly to the 
ulcers. This procedure will re- 
quire several days, and the pa- 
tient will suffer considerable 
pain before piles that are stran- 
gulated can be relieved, and 
patients should be made to un- 
derstand this from the start. 

5 urg ica 1. — Many authorities 
discountenance operation on 
piles that are strangulated, ul- 
cerated, or inflamed, until after 

the reduction of the tumours and inflammation and the healing of the 
ulceration. Gant advises an operation irrespective of their condition, 
so soon as the patient's consent can be obtained, for the reason that 
she will be about after a radical operation in a shorter time than it 
takes to reduce the inflammation. Many operations have been devised 
for the cure of hemorrhoids, but the injection, ]YhitelieacFs, the ligature, 
and the clamp-and-cautenj methods, are the only procedures worthy of 
special consideration. 

Injection. — This method was the rage ten years ago; to-day, it is 
resorted to only in carefully selected cases. Any one who is foolish 
enough to attempt to cure all piles, irrespective of location or condi- 
tion, by injecting them, will be sadly disappointed. He will not 
only fail to cure his patients, but will cause them much unnecessary 




Fig. 352. — " They may be large and protrud- 
ing, and may bleed occasionally." — Gant 
(page 850). 



852 A TEXT-BOOK OF GYNECOLOGY 

suffering and a greater loss of time than if they had had the clamp- 
and-cautery or ligature operation performed. This method of treating 
piles appeals to the patients because they do not have to take an an- 
aesthetic, submit to the knife, and suffer pain, and they are not pre- 
vented from following their occupations. This is true in successful 
cases; but in others, their suffering is excruciating, because of slough- 
ing, ulceration, abscess, or fistula, and they fail to be cured after all 
they have gone through. If only small pendulous piles, situated well 
above the grasp of the external sphincter, are injected, the results 
will be gratifying. Many solutions have been brought forward, but 
only those containing carbolic acid deserve commendation. This drug 
has been used successfully in combination with distilled water, glyc- 
erine, and olive oil, varying in strength from 4 to 75 per cent. Yount 
prefers the weaker, and Agnew the stronger, solution. Gant uses the 
following mixture: 

^ Carbolic acid 3j ; 

Glycerine, ) ^ ...aa 3i. 

Distilled water, j 

M. Sig. Inject from 5 to 10 drops in small, and from 10 to 15 in 
large piles, and see that they are pushed out of reach of the sphincter. 

Whitehead's Operation. — This operation consists in detaching the 
mucous membrane from the skin and dissecting it from the submucosa 
until the upper part of the pile-bearing area is reached; it is then 
amputated and the distal end brought down and sutured to the skin 
with silk sutures, which are allowed to cut their way out. Whitehead 
says that it is the most natural method, requires few instruments and 
little dexterity, and that there is less pain, and danger of secondary 
hemorrhage from it than after either the ligature or the clamp-and- 
cautery operations. The operation is radical, but Gant's experience 
bears him out in saying that it is difficult and bloody, and requires 
more instruments, a longer time to perform, and causes more pain 
owing to tension, than either the clamp-and-cautery or the ligature. 
Because of tension and the danger of infection, nonunion is common. 
As a result, the portion of the bowel between the anus and the retracted 
gut is uncovered by mucous membrane, leaving a broad circular ulcer- 
ated band that eventually terminates in stricture, incontinence, and 
pruritus. There is also an absence of the normal secretions to lubricate 
the faeces, and a loss of sensibility to warn the patient of an approach- 
ing stool. When primary union is obtained, these patients are up and 
about in two weeks. 

Ligature. — Only a few years ago nearly all the prominent surgeons 
of this country were doing the ligature operation. To-day, the clamp- 
and-cautery ranks equally with it in popularity, and in a few years 
more it will probably be the operation of election for the radical cure 
of piles. Hippocrates and Celsus used the ligature by simply placing 



NEOPLASMS OF THE RECTUM AND ANUS 



853 




Fig. 353. — " B. M. Ricketts uses the ligature subrau- 
cously, beginning at the muco-cutaneous margin." 
— Gant. 



it around the pile and allowing it to slough off. Modern surgeons first 
make an incision at the mucocutaneous border before applying the 
ligature, in order that the 
nerves may not be includ- 
ed, and severe afterpain 
may be thus avoided. The 
final result of either op- 
eration is equally good, 
for both effect a radical 
cure in a much shorter 
time, and with fewer com- 
plications and less incon- 
venience than any other 
operation. B. M. Eick- 
etts uses the ligature sub- 
mucously, beginning at 
the muco-cutaneous mar- 
gin (Fig. 353). The liga- 
ture may encircle in its 
sweep the bases of sev- 
eral tumours. Then, be- 
ing brought out at the 

point of original insertion, it is tied, causing subsequent atro- 
phy and disappearance of the hemorrhoids (Fig. 354). 

Clamp-and-Cautery. — 
This operation, as com- 
pared with the ligature, 
is comparatively new, yet 
it has been given sufficient 
trial by the profession to 
gain for itself an enviable 
reputation. Gant prefers 
this to the ligature opera- 
tion because after it there 
is less pain, spasm of the 
sphincter, and bladder dis- 
turbance, and patients are 
able to resume their oc- 
cupations more quickly. 
Hemorrhoids can be re- 
moved just as quickly with 
the clamp-and-cautery as 
with the ligature, and 
there is just as much dan- 
ger of secondary hemorrhage occurring after one as the other (Fig. 355). 
Before he devised his own clamp (Fig. 356) Gant had a serious hemor- 
rhage after this operation, due to an imperfect instrument allowing 




Fig. 354. — " Being brought out at the point of ori 
insertion, it is tied." — Gant. 



854 



A TEXT-BOOK OF GYNECOLOGY 



a part of the stump to slip through the clamp after the tumour had 
been cut away, and before there was an opportunity to cauterize it. 
He has also had the same accident because of a ligature slipping dur- 
ing a violent attack of coughing. Bleeding does not occur when 




Fig. 355. — "Hemorrhoids can be removed just as quickly with the clamp-and-cautery as with 
the ligature." — Gant (page 853). 

cauterization is properly done; the tissues should be thoroughly hurned 
with the cautery at a red heat, and the clamp loosened and read- 
justed if there is any bleeding. Gant has been doing this operation 
constantly for the past ten years and has not had a fatal hemorrhage 

or a stricture or other 
accident following it. 
Mathews says: " I use 
this plan (clamp-and- 
cautery) in selected 
cases, viz., where there 
is a large amount of skin 
around the anus, which 
is embraced in, or goes 




Fig. 356.— Gantfs clamp (page 853). 



to make up, a part of the internal hemorrhoid. If this amount of skin 
is cut off, excessive bleeding may occur. If an incision is made around 
it and it is ligated, we are chary about cutting too close to the liga- 
ture, and therefore we have much skin left and many ligatures." Gant's 






NEOPLASMS OF THE RECTUM AND ANUS 855 

experience has been the opposite of this; he has found that the bleed- 
ing f ollowing the removal of piles covered by skin is of no importance, 
and is easily arrested by a gauze compress. It is not surprising that 
patients thus operated on suffer great pain, for excruciating pain fol- 
lows the cauterization of the skin in any part of the body, and Gant 
never removes a skin pile by the clamp-and-cautery for this reason; he 
does operate on all internal hemorrhoids in this way, because there is 
so little post-operative pain when the cauterization is confined to 
mucous and submucous tissues. Allingham says: "My most careful 
researches have led me to a conclusion that it (clamp-and-cautery) is 
quite six times as fatal as the ligature, properly and dexterously ap- 
plied." He does not, however, point out what causes these fatalities, 
nor does he give statistics to substantiate his statement. Gant has 
never known of a person dying from this operation, nor has he seen such 
a case recorded in medical journals. Xo doubt there are cases of 
death from this cause on record, but the same can be said of the ligature 
operation. 



CHAPTER LIII 

PELVIC DISEASES AND NERVOUS AFFECTIONS 

Coincidence of pelvic and nervous diseases — Neurasthenia: Symptoms, conclusions 
— Hysteria : Symptoms, pathology, conclusions — Operations for the neuroses — 
Nervous symptoms of pelvic disorders. 

Coincidence of Pelvic and Nervous Diseases. — It has been thought 
wise that some one should present briefly in this treatise, from the 
standpoint of the neurologist, the essential facts in regard to the 
nervous affections to which women are especially liable. As is well 
known, pelvic and nervous diseases frequently exist concurrently in 
the same patient. This fact alone makes a consideration of the nerv- 
ous features of special importance. Besides, the advance made in the 
study of functional nervous diseases has been equally great with that 
made in gynecology. Views, new and comprehensive, now throw light 
upon fields where formerly there was only darkness and confusion. 

Neurasthenia is one of the two great neuroses to which women are 
especially liable, the other being hysteria. Too often the physician 
turns aside from the subject of neurasthenia as uninteresting, as 
being a term applied to a condition rather than a disease, and as pre- 
senting symptoms that are vague and ill defined, from a study of 
which nothing definite can be gained. In reality, neurasthenia is an 
exceedingly interesting affection; one which, far from displaying a 
vague and ill-defined symptomatology, presents a symptom group as 
fixed and as definite as that of any disease with which we are acquainted. 
It is true that, now and then, the symptoms differ widely in detail, 
but they always present the same essential features. They are always 
expressive of fatigue, and Dercum has, therefore, proposed for neu- 
rasthenia the far more expressive name of the fatigue neurosis. The 
stamp of fatigue is ineffaceably fixed upon every case. Every symp- 
tom is expressive of weakness, of irritability, and of ready exhaustion. 
A brief glance at the clinical picture will bear this statement out. 

The symptoms of neurasthenia resolve themselves into sensory, 
motor, general somatic, and psychic disturbances. Most of them are the 
direct result of chronic overfatigue; a smaller number are an indirect 
result, and these serve, at times, to complicate the picture. Dercum 
has separated the symptoms into two great groups : first, the primary or 
essential symptoms of neurasthenia; and, secondly, the secondary or 
adventitious symptoms. 
856 



PELVIC DISEASES AND NERVOUS AFFECTIONS 857 

Beginning with the sensory sy nipt urns we have, first, a general 
sense of fatigue or tiredness. This may be diffused throughout the 
entire bod} T , but is generally accentuated in special regions, e. g., the 
head, the back, or the limbs. It is characteristic of this sense of 
fatigue that, in the simple and typical cases, it is brought on if absent, 
or made worse if present, by effort. It is expressive of diminished 
power for the sustained expenditure of energy, and it is to be looked 
upon as one of the primary symptoms of neurasthenia. The sensation 
that characterizes it is one of generalized distress or discomfort diffused 
throughout the entire body, and is not referred to any particular re- 
gion. In this respect, it closely resembles the sensation of fatigue that 
follows prolonged exertion in perfectly healthy persons. However, if 
the conditions causing this general sense of tiredness persist, the sensa- 
tion ceases to be merely one of fatigue and becomes one of pain. In 
other words, when fatigue sensations become exaggerated, they become 
painful, and they are then described by the patient as aches of various 
kinds and are referred to special regions. Very commonly, for in- 
stance, the patient complains of headache. AVhen present in a mild 
degree, this headache is diffused, and is described as a dull feeling 
or a dull aching, and is then relieved by the mere cessation of work, that 
is, by rest. When it is more pronounced, it becomes accentuated in 
certain regions. Thus, it is referred especially to the occiput and the 
upper portion of the neck, and is often associated with sensations of 
drawing and tension. At other times, though less frequently, it is 
referred to the brow or to the vertex. Often other sensations are 
present, such as pressure, constriction, giddiness or ringing in the ears. 
These sensations are not themselves the direct outcome of fatigue, but 
belong to the group of the secondary or adventitious symptoms, men- 
tioned above. They may or may not be present. 

Xext in frequency to headache, patients complain of backache. 
This, at first, may consist of a simple feeling of fatigue referred to the 
lumbar region, which is relieved by lying down, but which, later, may 
become so exaggerated as to make backache the most prominent feature 
of the case. This backache is, as a rule, widely diffused over the lumbar 
region; it sometimes extends over the sacrum and gluteal regions, and 
at other times, and more frequently, upward over the dorsal region, 
especially between the shoulder blades. Often, cutaneous hyperes- 
thesia makes its appearance, so that the back, especially over the 
vertebra?, becomes sensitive to pressure. Frequently, this painful 
hyperesthesia is present in spots that can be covered by the tip of the 
finger. It is found especially over the seventh cervical spine, over the 
upper thoracic spine, sometimes over the lumbar spine and sacrum, 
and very frequently indeed over the coccyx. Without going into de- 
tails, it may be said that these symptoms, which were formerly and in- 
correctly grouped under the head of spinal irritation, clearly belong to 
the secondary, or adventitious, symptoms of neurasthenia. Not infre- 
quently, an especially painful spot is found slightly below and within 



858 A TEXT-BOOK OF GYNECOLOGY 

the left shoulder blade. Less frequently, a painful area is found in a 
similar situation below the right shoulder blade. 

Fatigue aches may also be referred to the limbs, namely, to the 
arms and shoulders, the hips, the thighs, or the legs. They consist, as 
a rule, of a dull aching, which is diffused through the tissues, generally 
diminished or relieved by rest and made worse by exertion. Limb 
ache is not infrequently associated with the special occupation of the 
patient. Thus Dercum has observed arm ache in a neurasthenic pocket- 
book-maker, leg ache in neurasthenic letter carriers and collectors, 
and not infrequently, as a matter of course, in neurasthenic sales- 
women. 

When we turn our attention to the phenomena presented by the special 
senses, we find that the symptoms are also expressive of chronic fatigue; 
but without stopping to analyze them here, as this would be too great a 
departure from the legitimate object of this chapter, it may be merely 
stated that the symptoms are those of ready exhaustion. As regards the 
eye, they are referable to fatigue of the accommodative apparatus, of 
the retina, or, it may be, of the cerebral centres. One of the common 
statements which we hear from neurasthenics is that they can not 
read for more than a few minutes at a time, that the letters become 
blurred, and that the effort gives rise to pain, generally headache or 
other cephalic distress, such as vertigo. Similar truths obtain with re- 
gard to the other special senses. 

When we turn to the motor symptoms of neurasthenia, we find that 
these, also, are expressive of fatigue. They consist more especially of 
muscular weakness, which develops rapidly under exertion, of tremor, 
and of various modifications of the tendon reactions. The object of 
this chapter forbids their discussion in detail, as well as a consideration 
of the visceral and general somatic disturbances. These have been fully 
considered elsewhere. Suffice it to say, that the disturbances of circula- 
tion, of digestion, of secretion, and of the sexual functions are, all of 
them, manifestations of chronic fatigue. For instance, the primary 
symptom referable to the digestive tract is that of digestion delayed 
and enfeebled, an atonic indigestion, both gastric and intestinal. The 
disturbances of circulation are manifested by feebleness of the pulse, 
coldness of the extremities, disturbances in the rhythm of the heart's 
action, and even by heart murmurs. The disturbances of secretion 
are evidenced by change in the character and quantity of the perspira- 
tion, of the urine, and of the saliva; these again are also purely and 
solely related to fatigue. When we turn our attention to the psychic 
disturbances, we find that they, too, are expressive of fatigue. A 
marked and characteristic symptom, namely, the diminution of the 
capacity for sustained intellectual effort, is invariably present. As the 
patient is incapable of long-continued physical labour, so is she in- 
capable of long-continued mental labour. The attempt to perform 
mental labour, sooner or later brings on symptoms of exhaustion, and if 
the task is persisted in, marked fatigue sensations make their appear- 



PELVIC DISEASES AND NERVOUS AFFECTIONS 859 

ance, especially headache. Associated with the impairment of the 
power of sustained effort, there is a lack of power of concentrating the 
attention, and this the patient frequently mistakes for loss of memory. 
In addition to these symptoms, there is a lack of spontaneity of thought 
and a diminution in the strength of the will, a condition of general 
indecision and of mental and emotional irritability. Frequently, fear 
also is present, and may assume a general or a special form; in the latter 
case, it gives rise to the various specialized fears, such as claustrophobia, 
agoraphobia, etc. 

If we pause to analyze the primary symptoms of neurasthenia, we 
find that they are always expressive of chronic fatigue, but there is 
present, as the essential condition, not only a marked and persistent 
diminution of nervous energy, but also an increased reaction, mental 
and physical, to external impressions. In other w T ords, to nervous weak- 
ness there is of necessity joined nervous irritability. Diminished re- 
sistance to fatigue implies diminished resistance to impressions from 
without; weakness and irritability are thus necessarily associated. This 
is seen, for instance, in the motor s}miptoms, where muscular weakness 
is associated with increased reflex excitability, and in the sensory symp- 
toms, where, to the fatigue sensations, there are sooner or later added 
the symptoms of local hyperesthesia; this is the explanation of the 
hyperesthesia so often found over the spinous processes, over the 
coccyx, and over various other areas. Another illustration of the same 
general truth is found in the fatigue of the eye; here, the patient is 
not only unable to use the eyes persistently, but there is also present, 
sooner or later, painful hyperesthesia, i. e., an irritability of the eye 
to light, so that neurasthenics often begin to wear smoked glasses of 
their own accord. It is this increased reaction to impressions from 
without that is of striking importance, as we shall presently see, when 
we deal with organic affections occurring in neurasthenic subjects. 

Briefly restating the facts, we find that the two cardinal conditions 
of the fatigue neurosis, neurasthenia, are (1) persistent nervous weak- 
ness, and (2) increased nervous irritability, that is, increased reaction 
of the organism to impressions from without. When we apply this 
interpretation of neurasthenia to the study of the diseases of the vari- 
ous" special organs, we find at once that a ready explanation is pre- 
sented for many of the strange facts we meet with. How remarkable it 
is that an eye defect often remains undiscovered for years; but a man 
who has become neurasthenic now finds that exertion of the eyes brings 
on headache, or makes headache worse, if present, because his resistance 
to fatigue has been diminished; in other words, an exertion so slight 
as to be utterly inadequate to evoke any symptoms whatever in a 
healthy man, may in a neurasthenic rapidly bring on a fatigue head- 
ache, now termed an eye headache. In the same way, a local defect or 
disease in other portions of the body may remain undiscovered so long 
as the general health remains good, and may only make itself felt when 
neurasthenia becomes established — i. e., when the nervous system pre- 



860 A TEXT-BOOK OF GYNECOLOGY 

sents the phenomenon of increased or abnormal reaction to local im- 
pressions. This fact has especial application to gynecology. It is well 
known that a woman with a laceration of the cervix or perineum, a 
displacement, or possibly a prolapsus, of the ovary, may make no com- 
plaint so long as her general health remains good; not infrequently, 
she fails to seek medical advice for the pelvic condition until neuras- 
thenia has become established. 

The foregoing considerations of neurasthenia warrant the following 
almost self-evident conclusions: 

First, that neurasthenia may exist independently of any local dis- 
ease, pelvic or otherwise. 

Secondly, that neurasthenia and pelvic disease may exist independ- 
ently in the same individual. 

Thirdly, that when pelvic disease is present with neurasthenia, the 
pelvic symptoms may be more readily recognised by the patient and 
therefore become more prominent, because in neurasthenia the reaction 
of the nervous system to abnormal or pathologic impressions is greatly 
increased. Without pausing to apply these conclusions to the question 
of surgical intervention let us turn our attention to hysteria. 

Hysteria, as has already been stated, is one of the two leading 
neuroses occurring in women. Dercum knows of no affection concern- 
ing which there is still so great a lack of knowledge in this country 
and in England, notwithstanding the fact that the French, and later 
the Germans, have unmistakably defined and described the symptom- 
atology of this disease. We frequently hear it stated, and almost as 
frequently see it printed, that hysteria is a disease without a syndrome; 
that it is a disease which presents an " infinitude of shifting polymor- 
phic nervous disturbances." This last phrase is borrowed from a text- 
book on the practice of medicine, published in this country no earlier 
than 1897; and nothing could be more untrue. In reality, hysteria 
presents a syndrome that is as fixed and as definite as that of any other 
disease with which we are acquainted. 

The symptoms of hysteria, particularly its cardinal symptom, like 
those of neurasthenia, are always present and always characteristic; 
while it is equally true that other symptoms, secondary in importance, 
are from time to time added, though the number of the secondary symp- 
toms is far less than those met with in neurasthenia. Dercum terms hys- 
teria a psychoneurosis because the physical symptoms present in it are 
dominated by mental phenomena, themselves the result of a genuine and 
profound affection of the cerebral centres. Prominent, for instance, are 
emotional disturbances and modifications of the will, but to these are 
added physical signs so striking that they can never be misunderstood. 
The symptoms of hysteria, like those of neurasthenia, consist of sensory, 
motor, general somatic and psychic phenomena. Let us begin with the 
sensory symptoms. In neurasthenia, the sensory symptoms consist for 
the most part of fatigue sensations combined with symptoms of sen- 
sory irritability. In hysteria, on the other hand, fatigue sensations are 



PELVIC DISEASES AND NERVOUS AFFECTIONS 861 

absent, but instead there may be present true anaesthesia, complete 
or partial; in other words, we are at once impressed with the fact ot 
true sensory loss, which never occurs in neurasthenia. Further, this 
sensory loss or anaesthesia is so characteristic as to enable us frequently 
to make a diagnosis of hysteria from it alone. Allusion need only be 
made to the symptom of hemianaesthesia,in which anaesthesia is confined 
to one half of the trunk and head, and to the limbs of one side. Strange 
to say, this sensory loss involves most frequently the left side. Again, 
the loss of sensation may be less widely distributed, in which case it is 
frequently characterized by peculiarities of location; for instance, it may 
be confined to a segment of a limb, that is, it may extend from the 
elbow to the wrist, or from the knee to the ankle, and is then termed 
segmental anaesthesia; again, it may cover the fingers, hand, wrist, and 
the arm up to a certain level, like a glove, and is then spoken of as 
glovelike anaesthesia; or it may cover the foot, ankle, and the leg 
up to a certain level, and then is spoken of as stockinglike anaesthesia. 
At other times, it assumes curious geometrical or irregular shapes. A 
fact which strikes the observer at once is the absence of correspondence 
between the various areas of anaesthesia and any nerve supply or any 
sensory representation in the spinal cord. This fact naturally refers 
us, while seeking for the seat of the disturbance, to the cerebrum. As 
regards hysterical hemianaesthesia, this cerebral involvement is fur- 
ther rendered probable by what we know of the pathology of organic 
hemianaesthesia, and it becomes still more probable when we reflect 
that the facts at our disposal lead us to infer that the representation 
of the limbs in the cortex is by segments. To sum up, therefore; in 
hysteria it is the distribution of the sensory loss which is characteristic, 
and which at once stamps it as hysterical. An important fact, however, 
should in this connection be borne in mind, and that is that the sen- 
sory losses in hysteria are most frequently far from being complete. 
Indeed, the most frequent condition that we find is that of diminution 
of response to tactile, to painful, and to thermal impressions, there 
being present under these conditions merely a general lessening of 
sensation, a hypo-aesthesia, or hypaesthesia — as it is termed technically. 
Partial sensory losses, therefore, having the peculiar distribution that 
has" been stated, are as unmistakable in their significance as total sen- 
sory losses, which are less frequently met with. 

Far more important, however, than anaesthesia or hypaesthesia, is 
the lujpercpsthesia which is found in hysteria. This, also, may have 
a most varied distribution, but as a matter of clinical fact it seeks by 
preference certain localities. Thus, most frequently, there are found 
areas of hyperaesthesia under the breasts, so-called " infra mammary 
tenderness," and areas of hyperaesthesia above the groins, grossly mis- 
named " ovarian tenderness." These areas of hyperaesthesia are some- 
times found on both sides of the body; more frequently, however, they 
are limited to one side of the body, and, curiously enough, like hemi- 
anaesthesia, they are found most frequently upon the left side. Areas 



862 A TEXT-BOOK OF GYNECOLOGY 

of hyperesthesia are also frequently found upon the scalp, and here 
the patch is often so small that it can be covered with a finger-tip. 

Not infrequently., these areas of hyperesthesia become areas of 
excessive pain, hyperalgesia. The areas are not only tender, but they 
become painful — not only painful to touch, but spontaneously painful. 
A familiar instance is found in the hypersesthetic area upon the scalp, 
which, when spontaneously painful, gives rise to severe headache, that 
form of headache known as clavus hystericus. What is true of the 
hypersesthetic area of the scalp, is also true of the hyperaesthetic area 
below the breast; sometimes it centres in the nipple and then gives 
rise to mastodynia. 

That both clavus and mastodynia are affections attended with much 
suffering, no one will deny. When the area of hyperesthesia in the 
inguinal region becomes painful, the suffering may be equally great. 
Owing to the anatomical relation which the inguinal region bears to 
the ovary, inguinal pain has been greatly misunderstood. As already 
stated, it has been misnamed ovarian tenderness, and has been directly 
attributed to the ovary; and yet there can be no doubt with regard to 
the nature of this pain, for we must remember that it is quite frequently 
found in men, as well as in women in whom the ovaries have been 
removed — removed sometimes in a vain attempt to relieve this pain. 
The pain is not ovarian; it should never have been called ovarian. 
Inguinal tenderness, groin pain, or, as Dercum prefers, inguinodynia, 
are terms much simpler and in strict accordance with facts. The pain 
is, as a rule, confined to a limited area, and is found most frequently 
upon the left side; and it is very often associated with a similar, 
though somewhat larger, area of tenderness beneath, or over, the left 
mammary gland, and, it need hardly be added, with other definite, well- 
marked hysterical stigmata. As a rule, it is revealed, by careful exami- 
nation, to be superficial and not deep. It is situated in the skin and 
the tissues of the abdominal wall, and not within the pelvis. Dercum 
has frequently demonstrated this to be a fact by means of the following 
procedure: 

The painful area having been carefully localized on the abdominal 
surface, the tip of the forefinger of the right hand is allowed to rest 
lightly upon it; the left forefinger is then introduced into the vagina 
and directed upward and to the right, until its tip is immediately be- 
neath the tip of the forefinger of the right hand which is upon the 
abdominal wall. Just as soon as .pressure is made between the two 
fingers, the patient flinches; while the patient does not flinch when 
pressure is made in other directions or when other portions of the 
abdominal wall are included. By this means Dercum has succeeded 
not infrequently in isolating and demonstrating beyond a doubt the 
site, and therefore the character, of this pain. In some cases, just as 
in spinal tenderness, the pain radiates and becomes somewhat diffused; 
but it always radiates from a superficial centre in the abdominal wall; 
and just as there are cases of spinal tenderness in which the tenderness 



PELVIC DISEASES AND NERVOUS AFFECTIONS 863 

is at one time superficial, and at another deep, so there are cases of 
inguinal tenderness in which the tenderness seems at times to be deep- 
seated; but even here, by the procedure just described, the maximum 
point of pain can always be isolated and shown to exist in the abdom- 
inal tissues. This hysterical inguinal pain has frequently forcibly sug- 
gested to Dercum the clavus hystericus — the boring penetrating pain 
that hysterical patients feel in limited areas about the head; and, 
indeed, not infrequently this inguinal pain is just as severe, but it is 
no more intrapelvic in its origin than is the clavus of the head. 

It is not necessary to speak of the contracture of the visual fields 
in hysteria, nor of the reversal of the colour fields, as they do not in 
this chapter directly concern us. They must, however, be borne in 
mind as affording valuable corroborative evidence of the existence 
of hysteria. The motor symptoms of hysteria are less frequently met 
with than the sensory disturbances which we have just considered. The 
motor symptoms consist, in brief, of paralysis, contracture, tremor and 
inco-ordination. The presence of motor symptoms generally causes the 
case to be referred to the neurologist in the beginning, rather than to 
the gynecologist, and they, therefore, will not be considered in this con- 
nection. Similarly, with the visceral symptoms, which consist of dis- 
turbances of digestion, of the circulation, of the heart, of respiration, 
of fever, of cough, of loss of voice, of yawning, of phantom tumours, 
etc. They also are less likely to come before gynecologists for inter- 
pretation, and, moreover, are so characteristic as to stamp the case at 
once as hysterical. 

The psychic symptoms of hysteria, however, are important for the 
gynecologist. There is always some abnormity of the mental faculties 
in hysteria, more particularly a hyperesthesia and irritability of the 
affectional or emotional faculties. The patient is, as a rule, exceedingly 
impressionable, and reacts inordinately to impressions involving these 
faculties. She is abnormally sensitive to suggestions, especially with 
regard to her physical condition, and willingly accepts explanations 
attributing her symptoms to local disease. Not infrequently, hysterical 
symptoms are brought to the surface, or, if present, are made promi- 
nent, by the ill-considered statements or injudicious interest manifested 
by "the patient's friends. It can be readilv seen how doubly injurious 
under such circumstances incautious statements by a physician, or a 
pelvic examination, even when the latter yields a negative result, may 
be. One can hardly judge of the enormous mental impression a first 
examination must make upon a young girl, especially if that girl is 
already hysterical, already neuropathic by heredity and predisposition. 
Not only is the great evil of the moral shock to be taken into account, 
but also the fact that there is lodged in the patient's mind a more or 
less vague but fixed belief that she has some mysterious local disease 
to which she only too willingly agrees to attribute her nervous mani- 
festations. In consequence, she sooner or later insists upon a repeti- 
tion of the examination or a continuance of the local treatment once 






864: A TEXT-BOOK OF GYNECOLOGY 

begun, and the morbid idea thus implanted may become hopelessly 
rooted, never, perhaps, to be displaced. The enormous role which the 
mental condition in hysteria plays, must constantly be borne in mind. 
Hysteria appears to be a functional disturbance of the entire nervous 
system, but with a special involvement of the cerebral cortex. 

The conclusions that the above considerations justify, are the fol- 
lowing: 

First, that hysteria may exist independently of any local disease, 
pelvic or otherwise. 

Secondly, that there is no essential relation between pelvic dis- 
ease and hysteria, even when the two affections coexist in the same 
case. 

Thirdly, that while in hysteria there is an increased reaction to 
external impressions, this reaction is purely psychic. The patient is 
exceedingly impressionable, and reacts inordinately to impressions in- 
volving the affectional or emotional faculties. This reaction to external 
impressions differs altogether from that seen in neurasthenia, for, in 
the latter, the reaction involves the nervous system as a whole. In 
hysteria, the patient readily accepts the suggestion — often a spontane- 
ous self-suggestion — of pelvic disease, especially as groin pain is so 
common a symptom of hysteria. 

Fourthly, that the pain areas of hysteria bear no relation to dis- 
ease of the deeper structures. 

Operations for the Neuroses. — Evidently the surgeon can not hope 
by operation to remove the symptoms characteristic of the neuroses, 
but only those symptoms properly belonging to the pelvic disease itself; 
and his operation should never be undertaken for any other purpose. 
To state the truth in other words, the surgeon should operate for the 
pelvic condition itself. For instance, if he operates on a tear of the 
perineum, he should do so because the tear has resulted in mechanical 
difficulties — because it has given rise to a displacement of the uterus 
or perhaps to a rectocele, not because the tear occurs in a neurasthenic 
or hysterical woman. If he removes an ovary, it should be because the 
ovary is unmistakably diseased. If he removes an appendix, he should 
do so because the characteristic symptoms of appendicitis are present, 
and not because the patient suffers from neurasthenia or hysteria. If 
he sews fast a movable kidney, it should be because the mobility of 
the organ is such as to threaten mechanical obstruction of the ureter 
with its consequent hydrops of the kidney, or because the patient suffers 
from irregularly recurring attacks of gastro-intestinal cramp directly 
dependent upon the abnormal mobility of the organ, and not because 
she is neurasthenic or hysterical. Operations should be performed, not 
for the relief of an incidental nervous symptom, but because of the 
local condition itself; just as we set a broken leg in an insane man, 
not because he is insane, but because the leg is broken. 

The surgeon should approach cases of neurasthenia and cases of 
hysteria somewhat differently. Contrary to what might, perhaps, be 



PELVIC DISEASES AND NERVOUS AFFECTIONS 865 

inferred, Dercum believes that, in neurasthenia, operations for the 
•cure of actual pelvic lesions are indicated, and. should, other things 
being equal, be performed. We remember that in neurasthenia there 
is added to nervous weakness, nervous irritability; that there is an in- 
creased reaction to local disease, and it is just as clearly indicated to 
correct local pelvic disease in neurasthenic patients as it is to give 
.such patients glasses to relieve their ocular symptoms. It is important, 
however, in considering operations upon neurasthenics, to bear in 
mind that these patients are excessively sensitive to nervous shock. All 
gynecologists are familiar with the persistent nervous symptoms — the 
persistent surgical neurasthenia — that ensues in some patients after 
pelvic operations. If such operations are undertaken upon persons 
already neurasthenic, great harm may be done. Therefore, if, in a 
•case requiring pelvic operation, neurasthenia is present in any degree 
(provided, of course, that the operation is not urgently indicated for 
surgical reasons), Dercum believes that the patient does better if the 
■operation is preceded by a period of rest. If the patient, instead of 
being neurasthenic, is hysterical, a period of preliminary rest is even 
more strongly indicated. This he believes to be specially true when 
the hysteria is very profound. In the latter case, operation should be 
■deferred, unless, of course, the surgical indications are urgent. 

Nervous Symptoms of Pelvic Disorders. — A view is entertained by 
many physicians that certain nervous disorders are the direct result of 
pelvic lesions. Unfortunately, the increase of our knowledge regarding 
functional nervous diseases does not bear out these assertions. The 
nervous symptoms caused by pelvic disease are, as a matter of fact, 
exceedingly limited. It is true that there is present pelvic pain, pain 
referred to the back and to the hips and thighs, together with more or 
less marked indications of general ill-health, but certainly these symp- 
toms can not be dignified by the term of a nervous disorder. They are 
-a part of the pelvic disease itself, and are directly symptomatic of it. 
They do not constitute neurasthenia or hysteria. 

Many years ago a doctrine, known as the doctrine of reflex nervous 
disorders, had an exceedingly strong hold upon the profession. An 
increasing knowledge of the various functional nervous diseases has 
demonstrated this doctrine to be utterly fallacious. Long since, the 
practice of circumcision for epilepsy has been abandoned, as has also 
the removal of ovaries for the cure of the same disease and of hysterical 
convulsions. Both procedures had equally little foundation and both 
were equally unscientific and barbarous. 

The reader can readily understand why it is unnecessary to discuss 
the relation between the pelvic disease and epilepsy, chorea, and other 
nervous diseases. The truth can all be summed up in a word, there is 
no relation. The same truth obtains with regard to the insanities. For 
instance, the various abnormities of menstruation that are observed 
in the course of an insanity, are the indirect sequela? of the general ill- 
health from which the patient suffers, and not due to any apocryphal 
56 



866 A TEXT-BOOK OF GYNECOLOGY 

relation between the condition of the pelvic organs and the insanity. 
Insanity, like epilepsy, depends upon morbid changes within the ner- 
vous system itself; these changes in turn being dependent, in all proba- 
bility, upon profound, and as yet undetermined, changes in the general 
nutrition of the organism. The statement is sometimes made that 
insane patients who have been subjected to operation sometimes get 
well, but we should remember that a lucid interval or even an apparent 
cure sometimes follows a mere physical shock, such as a fall or other 
trauma. Indeed, a recovery is not an infrequent result of some inter- 
current infectious malady, such as erysipelas or typhoid fever. 

A full and dispassionate consideration of the entire subject leaves 
to the surgeon no other option than to operate for surgical indications 
only, and, in certain cases, where the nervous disorder is grave, as in 
profound hysteria, profound neurasthenia, and in insanities attended 
with great exhaustion, operation should be undertaken only when the 
surgical indications are urgent. (See Indications for Oophorectomy.) 






IKDEX 



Abbe, 692. 

Abdomen, auscultation of. 40. 
bandage for, 111; illus., p. 112. 
massage, 24. 
noupendulous, 466. 
pendulous, 466; illus., p. 467. 
percussion of, 40. 
palpation of, 40. 
regions of. 41: illus., 41. 
Abdominal section, 99. 
drainage in. 114. 
instruments for, 103. 
location of incision, 103. 
making the incision. 107. 
preliminary treatment for, 100. 
preparation of field, 66. 
terminology, 99. 
Abel, 362, 389. 556. 

Abortion, as a cause of menorrhagia, 716. 
as a cause of metrorrhagia, 719. 
criminal. 10. 
tubal, 655. 
Abscess, ischiorectal, 826. 
kidney, 768. 
metastatic, 57, 58. 
pelvic, 689. 

vulvo-vaginal, gland. 245. 
Absence of, Fallopian tubes, 473. 
byinen, 133. 
kidney, S49. 
ovary, 560. 
rectum, 806. 
uterus, 276. 
vagina, 126. 
Adamkiewicz, 442, 443. 
Adams, 294. 
Adenoma ma lignum evertens, 430. 

invertens, 430: illus.. p. 431. 
Adenoma, of kidney, 782. 
histology, 782. 
ovary, contents, 620. 

histology, 620. 
rectum, 841. 
symptoms, 842. 
treatment, 842. 
uterus, 429. 
cautery in. 431. 
curettage in. 431. 
hemorrhage from, 431. 
recurrence of, 432. 
treatment, 431. 



Adenomyoma of uterus, 397, 399. 
Adenosarcoma of kidney, 7S3. 

histogenesis, 784. 
Adhesion, as a complication of ovarian tu- 
mours, 631. 

inguinal, 297. 

labial, 120, 212. 

of movable kidney, 717. 

preputial, 120, 211. 
treatment, 212. 

rectal, 832; illus.. 822. 

separation of, 547; illus., p. 548. 

treatment of, 294. 

treatment of, in ovariotomy, 642. 

vulvar, 211. 
Accidents, in anaesthesia, 95. 

hysterectomy, 415. 
Acconci, 576. 
Aetius, 1. 
Afanassiew, 166. 
Ahlfeld, 436. 
Air embolism, 74. 

in use of chloroform. 94. 
Albarran. 747, 760, 763, 764, 707, 772. 791. 
Albicans oidium, 167. 
Albuminuria, 631. 
Alcohol, as an anaesthetic, 97. 
Alexander, 294. 295, 297, 303, 305, 309, 324. 

361, 564. 
Alexander's operation on round ligament. 

294. 
Allingham. 855. 
Allis inhaler, 92; illus., p. 92. 
Aloe. 835. 
Alquie, 294. 
Altormyan, 394. 
Alvard, 448. 
Amann, 434, 440. 
Ameiss, 278, 279. 
Amenorrhoea, acquired, 721. 

frequency of. 720. 

treatment. 721. 
Amputation of the cervix, 340: illus.. p. 

342. 
Anaemia, as a cause of amenorrhoea, 722. 

as a cause of menorrhagia, 714. 

causes. 722. 

treatment. 722. 
Anaesthesia. 87. 

accidents in. 95. 

alcohol in, 97. 

867 



868 



A TEXT-BOOK OF GYNECOLOGY 



Anaesthesia, cause of bronchitis, 91. 

central, 97. 

cyanosis in, 90. 

for children, 91. 

hypnosis for, 98. 

in examination, 40. 

kidneys in, 102. 

local, 98. 

manipulation of head, 96. 

sexual, 9. 

struggling in, 90. 

vomiting in, 91. 
Anaesthetic agents, 87. 

selection of, 88. 
Anatomy, of corpus luteum, 13. 

Fallopian tubes, 489. 

hair follicle, 199. 

movable kidney, 755. 

parovarium, 670. 

pelvic floor, 250. 

rectum, 806. 

urachus, 803. 

vulvo-vaginal glands, 243. 
Anderson, 41. 
Andrews, Edmund, 441. 
Angeiodystrophia ovarii, 17. 
Angeioma of kidney, 781. 

rectum, 843, 844. 
Angeiosarcoma, 624. 
Angeiotribe, 81. 

for hemostasis, 81. 

in panhysterectomy, illus., p. 419. 
Animal extracts, 21. 
Animals, menstruation of, 699. 
Anomalies, see Malformations. 
Anoscope, 812. 

use of, 814. 
Ante-deviations of the uterus, 310. 

cuneohysterectomy for, 315. 

curettage for, 312. 

diagnosis of, 310. 

dilatation for, 312. 

pathology of, 311. 

surgical treatment of, 312. 

symptoms of, 310. 

treatment of, 311. 
Antisepsis, 56, 60. 

post-operative, 68. 

precautions for, 295. 
Anuria, 780. 
Anus, fissure of, 820, 832. 

imperforate, 120. 

malformations of, 806. 

ulcer of, 832. 

vulvar, 121; illus., p. 122. 
Aphthae of external genitalia, 179. 

treatment, 179. 
Apostoli, 24, 680. 
Appendicitis, diagnosis of, 504. 
Appetite, sexual, 588. 
Approximation of abdominal incision, 104, 

105. 
Aretaeus, 328. 
Arloing, 180. 
Armamentarium, 27. 



Armamentarium, gynecological, 27. 

office examination, 31. 
Aron, 388. 
Asche, 235. 
Aschoff, 231, 769. 
Ascites, 630. 

as a complication of ovarian tumour, 
635. 
Asepsis, 56. 

Ashton, W., 348, 349, 735. 
Askanazy, 174. 
Aspiration, 546. 

as a means of examination, 47. 

instrument for, 546; illus., p. 546. 
Assault, indecent, 160. 
Astringents, 22. 
Astruc, 1. 
Atlees, 638. 
Atmocausis, 367. 

Atresia ani vestibularis, 221; illus., p. 122. 
Atresia, of cervix, 279. 

Fallopian tubes, 495. 

hymen, 132. 

ureters, 150. 

vagina, 126; illus., p. 127. 

vulva, 119; illus., p. 119. 
Atrophy of, ovaries, 592. 
causes, 592. 
symptoms and treatment, 593. 

uterus, 18. 

vulva, 207; illus., p. 208. 
diagnosis, 210. 
etiology, 208. 
treatment, 210. 
Auscultation of abdomen, 40. 
Auto-infection, 165. 
Avicenna, 328. 
Aveling, 329. 
Ayner, 764. 

Bacilli, 53; illus., p. 54. 
Bacillus aerogenes capsulatus, 54; illus., 
p. 58. 

infection by, 180. 
Bacillus coli communis, illus., p. 54. 
Bacillus coli infection of Fallopian tubes, 
487, 528. 

causes, 528. 

pathology, 529. 

symptoms, 528. 
Bacillus coli, infection of ovary, 575. 
Bacillus diphtheria, 167. 
Bacillus phlegmonis emphysematosus, 180. 
Bacillus tuberculosis, 55; illus., p. 54. 

infection by, see tuberculosis of. 
Bacini, 677. 
Bacon, 18, 212, 427. 
Backer, 358. 
Bacteria of, cervix, 353. 

chancroid, 183. 

cystitis, 791. 

Fallopian tubes in disease, 484. 
in health, 484. 
methods of access, 486. 

external genitalia, 163. 



INDEX 



869 



Bacteria of lochia, 166. 

ovaries, 570. 

puerperal fever, 376. 

pyosalpinx, 485. 

renal infection, 769. 

salpingitis, 484. 

sepsis, 18. 

uterus, 352. 

vagina, 163. 
Baer, 720, 740. 
Bagot, 683. 

Baldy, 136, 257, 678, 680. 
Ball, John, 312, 313, 833. 
Ballantyne, 120, 121, 122, 123, 124, 127, 
131, 133, 134, 279, 318, 473, 474, 475, 
562. 
Ballottement, 634. 
Ballowitz, 749, 750. 
Balneotherapy, 22. 
Band, vestibular, 131: illus., p. 132. 
Bandage, abdominal, 111; illus., p. 112. 
Bandelocque, 463. 
Bandl, 331, 683. 

ring of, 332. 
Bandouin, 294. 
Bangs, 774. 
Bantock, 588, 6 
Barbier, 131. 

Barnes, Robert, 329, 461, 649, 700, 711. 
Barth, 478. 

Bartholin, glands of, 243. 
Bartlet, H. L., 459. 
Baruch, 367. 
Basedow, 712. 
Bath, sitz, 204. 
Battey, 2, 584, 723. 
Battey's operation, 584. 
Battle, 778. 
Beaucoudray, 617. 
Becker, 753. 
Bell, 638. 
Benbrook, 346. 
Bennet, 2. 
Berggrun. 694. 
Bergh, 200. 
Bergmann, von. 24. 
Bernard, 192, 763. 
Bernitz, 649. 
Bernhardes, 279. 
Bettman, 209. 
Bicornate uterus, 281: illus., p. 279. 

menstruation from, 280. 

symptoms, 278. 
Bigeard. 458. 
Bilharz. 180. 

Bilharzia, of vagina, 180. 
Billroth. 24. 638. 626. 
Bimanual examination, 37: illus.. p. 37. 
Birch, 781, 783. 
Bitner, 123. 
Blacker, 562. 
Bladder, calculus in. 140. 141. 

congestion of. 780. 

infection of. 791. 

inflammation of. 790. 



Bladder, neuralgia of, 795.' - 

tumours of, 798. 
Blondel, 277. 
Blood cyst, of corpus luteum, 600. 

structure, 601; illus., p. 601. 
Blood, examination of, 49. 

extravasation of, 492. 

transfusion of, 76. 
Bloom, 737. 
Blot. 473. 
Blumer, 514. 
Blundell, 471. 
Bockart, 53, 198. 
Bode, 294. 

Bodenhamer, 806, 807. 
Bodenstein. 867. 
Boeck, Caesar, 216. 
Boisleux. 503. 
Bossi, 37U. 
Bovee, 477. 647, 648. 
Bouilly, 458. 
Bowditch, 5. 
Bozeman. 148. 
Bozeman's dressing forceps, illus.. p. 369. 

table, 143. 
Braetz, 434. 
Brain weight, 7. 
Brandt. Thure, 25, 353. 359. 
Braun. Carl. 180, 324, 329, 681. 
Braxton-Hicks, 725. 
Brehmer. 692. 
Breisky, 207, 208, 429. 
Brenner. 747. 
Broese, 372. 373. 
Bromide of ethyl, as an anaesthetic, 91. 

administration of, 95. 
Bronchitis as a result of anaesthesia. 91. 
Brosson. 204. 
Brown, Baker, 638. 
Browne. Sir J. Crichton, 7. 
Brues, 389. 
Bruhn, 229. 
Brunn. 692. 
Bubo. 515. 

chancroidal, 181. 

internal. 392. 
Buchner. 698. 
Buckmaster, 122. 

Buds, syncytial, 427; illus., p. 428. 
Bulbo-cavernosus muscle, 250. 
Bulius, 17. 599, 610, 695. 
Bulkley, 206. 
Bullard. J. TV.. 257. 
Bumm. 16. 52. 53. 244. 246, 353. 354, 376, 

377. 378. 379. 517, 617. 69S. 791. 
Burns. 462. 
Burow, 193, 196. 
Byford, 257. 294. 301. 302. 546. 
Byrne. John, 83. 456, 458, 459. 
Byrne's electro-hysterectomy, 456: illus., 
p. 546. 

Csesarean section. 460. 
after-treatment. 470. 
closure of uterus, 469. 



870 



A TEXT-BOOK OF GYNECOLOGY 



Csesarean section, clangers of, 465. 
definition, 460. 
diet, after operation, 470. 
drainage after, 469. 
hemorrhage in, 467. 
history, 460. 
indications, 463. 
instruments, 465. 
ligation of tubes, 469. 
location of incision, 466; illus., 466, 467. 
manipulation of fcetus, 467. 
measurement of pelvis, 464. 
position of foetus, 465. 
Porro's modification, 471. 
preparation of patient, 465. 
removal of placenta, 468. 
removal of sutures, 470. 
results, 462. 

rupture of membranes, 470. 
Sanger's method of closure, 470. 
technique, 466. 
treatment of tubes, 468. 
Calcareous tumours of, corpus luteum, 
617. 
ovary, 615. 
etiology, 617. 
histology, 616. 
treatment, 618. 
Calculi, renal, 776. 
etiology, 776. 
pathological changes, 778. 
primary, 776. 
removal of, 761. 
secondary, 777. 
stricture from, 761 
symptoms, 778. 
treatment, 780. 
Calculi, vesical, 140, 141, 796. 

removal, 798. 
Calyces, dilatation of, 763. 
Cameron, 462, 463, 465, 471. 
Camescasse, 514. 
Canquoin, 366, 370. 
Capsularis, in ectopic pregnancy, 658. 
Carcinoma, bacillus of, 441. 
Carcinoma of, broad ligament, 386. 
cervix, 362, 438. 
ovary, 619. 
adenocarcinoma, 620; illus., p. 620. 
medullary, 619. 
primary, 619. 
secondary, 622. 
portio vaginalis, 438. 
rectum, 844. 
stricture from, 838. 
symptoms of, 845. 
treatment, 845. 
urethra, 801. 

uterus, 447; illus., p. 440. 
age influence, 440. 
amputation of cervix for, 447. 
cauterization for, 447. 
complications, 443. 
course, 439. 
curettement for, 447. 



Carcinoma of uterus, diagnosis of, 442. 
diagnosis, by inoculation, 443. 
discharge in, 442. 
electro-hysterectomy for, 456. 
etiology, 440. 
■ extended operation for, 453. 
hemorrhage in, 442. 
histology of, 439. 
hysterectomy for, 447. 
involvement of lymphatics, 439. 
metastasis from, 481. 
mortality in, 437. 
mortality from operations, 458. 
origin, 438, 441. 
panhysterectomy for, 417. 
pathology, 438. 
pregnancy in, 443. 
prognosis, 444. 
radical treatment, 447. 
recurrence of, 458. 
results of hysterectomy, 458. 
removal of vagina for, 455. 
serum treatment, 446. 
symptoms, 442. 
tampon for, 446. 
topical medication, 444. 
vaginal hysterectomy for, 447. 
vagina, 233. 
primary, 233. 
secondary, 234. 
vulva, 227. 
classification, 227. 
prognosis, 228. 
vulvo-vaginal gland, 228, 249. 
Carniso, 470. 

Carstens, 444, 445, 446, 453. 
Cartledge, 377, 383, 603. 
Caruncle, urethral, 800. 

treatment, 801. 
Casper, 772, 747. 
Castex, 328. 
Castration, 407. 
Catgut, suture, 67, 337. 
Catheter, glass; illus., p. 368. 

use of, 148. 
Catheterization of ureters, 746. 
by cystoscope, 747. 
Pawlik-Kelly method, 746. 
Caustic, in treatment of syphilis, 190. 
Cauterization, for carcinoma, 445. 
condylomata, 210. 
hemorrhoids, 853. 
hemostasis, 80. 
syphilis of uterus, 393. 
tubercular endometritis, 391. 
Cautery, Paquelin's, 80. 

thermo-, in vaginal hysterectomy, 449. 
Cazeaux, 463. 
Cazin, 427, 428. 
Celsus, 852. 

Central anaesthesia, 97. 
Cervix, amputation of, 340; illus., p. 342. 

for carcinoma, 447. 
Cervix, atresia of, 279. 
bacteria of, 352. 



INDEX 



871 



■Cervix, carcinoma of, 362, 438. 

chancre of, 392. 

dilatation of, 356, 364, 421, 726. 

eversion of, 392. 

fixation of, 304. 

function of, 350. 

hypertrophy of, 319, 335; illus., 320. 

immunity of, 355. 

in endometritis, 364. 

laceration of, 334. 

menstruation from, 435. 

secretion of, 353. 

tuberculosis of, 385. 
Chadwick, 394. 

Chain tampon, 292; illus., p. 292. 
Chamberlain, 61, 461. 
Chancre, cervical, 392. 

ecthymatous, 185. 

exulcerated, 186. 

hard, 184, 201. 

pudendal, 181. 

rectal, 828. 

uterine, 391. 
Chancroid, 181. 

course of, 182. 

diagnosis of, 175, 183. 

pathology, 183. 

prevalence,. 182. 

phagedenic, 181. 

rectal, 828. 

treatment, 184. 

vulvar, 228. 
Chancrous erosion, 185. 
Chantemesse, 379. 
Charcot, 98. 
Chase, W. D., 721. 
Chassaignac, 808. 
Chenieux, 686. 
Cheyne, 750. 
Chiari. 180, 521. 
Chiarleoni, 120. 

Childbirth, as a cause of disease in 
women. 10. 

as a cause of uterine displacement, 206. 
Children, anaesthesia for, 91. 
Chloroform, administration of, 94. 

inhaler. 94. 

relative safety of, 88. 
Chlorosis, as a cause of monorrhagia, 714. 
Chorio-epithelioma, see Syncytioma malig- 

num. 
Chrobak, 580. 

Cilia, of endometrial epithelium, 351. 
Circumcision. 120. 220. 
Cirrhosis, of ovaries, 593. 

causes. 593. 

symptoms, treatment, 594. 
Civilization, as a cause of disease, 6. 
Clado, 791. 
Claisse, 682. 

Clark, 13, 115, 478, 479, 488, 496, 534. 
Clavus hystericus, 862. 
Clay, 436, 638. 

Clamp, electric, in panhysterectomy, 419. 
Clitoridectomy, 234; illus., p. 234, 235. 



Clitoris, diseases of, see Vulva. 

epithelioma of, 228; illus., 229. 

excision of, 234; illus., p. 234, 235. 

glands of, 118. 

hypertrophy of, 126, 213. 

malformations of, 124. 
Clivio, 52, 178, 376. 
Cloaca, 117. 

persistent, 121; illus., p. 122. 
Closure of abdominal incision, 109. 

of perineal incision, 260, 265. 

of uterine incision, 469. 

for drainage, 113, 111. 
Clover's crutch, 260. 
Cocaine, as an anaesthetic, 97. 
Cocci, pyogenic, 165. 
Coe, 257, 429, 431, 478, 480, 538, 540, 547, 

551, 592, 617, 670. 
Coeliotomy, see Abdominal section. 
Cohn, 622. 
Cohnheim, 609, 617. 
Cohnstein, 711. 
Coitus, 119. 

as a cause of disease, 9. 

injuries from, 136. 
Coitus reservatus, 10. 
Cold, in anaesthesia, 89. 

in treatment of sepsis, 56. 
Coley, 436. 

Colica scortorum, 502. 
Colley, 100. 
Collodiou. 111. 
Colombeni, 374, 375. 
Colostomy, 846. 

for rectal prolapse, 820. 
Colporrhaphy, anterior, 241; illus., p. 239. 

posterior, 242. 

technique. 323. 
Coma, alcoholic, 97. 
Comby, 754. 

Commissure, vulvar, 123. 
Compress, for pruritus vulvae, 205. 
Conception, prevention of, 10, 469. 

relation to menstruation, 711. 
Condylomata, 187, 213; illus., p. 214. 

cauterization of, 216. 

microscropic examination of. 214. 

rectal, 828: illus., p. 829. 

treatment, 215. 
Conservatism, in gynecology. 4. 

in operations on the Fallopian tubes, 
546. 

in operations of the ovary, 543. 
Constipation as a cause of amenorrhoea, 
722. 

as a cause of genital disorders, 9. 

as a cause of uterine displacement, 
286. 

as a cause of rectal disease, 507. 

from obstruction: illus., p. 508. 

treatment, 100, 321, 717. 
Cook, 733. 
I Cooper, 844. 
Cordier, 326, 604. 
Cornil, 386, 387, 388, 389. 



872 



A TEXT-BOOK OF GYNECOLOGY 



Corning, J. Leonard, 97. 
Corpora cavernosa clitoridis, 118. 
Corpus luteum, anatomy of, 13. 

calcareous tumours of, 617. 

cysts of, 599. 
Corpus luteum verum, 660. 
Corpus spongiosum, 118. 
Corset, as a cause of genital disorders, 8. 

as a cause of movable kidney, 54. 

dangers of, 729. 
Coughlin, 733. 
Courty, 281. 
Crab louse, 206. 
Cragin, 750. 
Craig, Thomas C, 51. 
Craniotomy, results of, 462. 
Crampton, 327. 
Crile, 72, 75. 
Criminal abortion, 10. 
Cripps, 844. 
Crosse, 327. 
Crown suture, Emmet's, 262; illus., p. 262. 

Reed's, 263; illus., pp. 264, 265. 
Crutch, Clover's, 260. 
Cullen, 389, 497. 
Cullen's tenaculum, 450. 
Cullingworth, 281. 
Cuneohysterectomy, anterior, 310. 

modifications, 317. 

posterior, 315; illus., p. 316. 

technique, 316. 
Curatullo, 589. 
Curettage, 368. 

after-treatment, 371. 

anaesthesia for, 92. 

contraindications, 369. 

exploratory, 364. 

for adenoma uteri, 431. 

for ante-deviations of uterus, 312. 

for carcinoma uteri, 444. . . 

for puerperal fever, 381 . 

for tubercular endometritis, 391. 

indications, 313, 369. 

instruments for, 368. 

rectal, 846. 

technique, 313. 
Curette, Gau's, 346; illus., p. 346. 

Martin's, 568. 
Currier, 6, 369. 
Cushing, Clinton, 541. 
Cyanosis, in anaesthesia, 90, 94. 
Cycle, menstruable, stage of degeneration, 
709. 

stage of growth, 708. 

stage of recuperation, 709. 

stage of rest, 708. 
Cyst, dermoid, 14, 224, 225, 611. 

emptying of, in ovariotomy, 641. 

tubo-ovarian, 498. 
Cyst of, Bartholin's gland, 228. 

broad ligament, 674. 
causes, 674. 
complications, 674. 
contents, 673. 
development, 672. 



Cyst of, broad ligament, diagnosis, 674. 

enucleation, 676. 

frequency, 671. 

history, 671. 

origin, 671. 

pain in, 674. 

rupture of, 675. 

symptoms, 674. 

technique of operation, 676. 

treatment, 675. 
corpus luteum, 594; illus., p. 600. 

blood cysts, 600. 

contents, 600. 

development, 599; illus., p. 600. 

etiology, 600. 

histology, 600. 

structure, 601; illus., p. 601. 
Gartner's duct, 224. 
hymen, 224. 

Kobelt's tubules; illus., p. 475. 
ovary, 597. 

characteristics, 597. 

corpus luteum cysts, 599. 

dermoid, 611. 

follicular cysts, 598; illus., p. 598. 

malignant degeneration, 611. 

papillary cysts, 607. 

papillomata, 609. 

pseudomucinous, 603. 

puncture of, 637. 

rupture, 631. 

serous, 607. 

teratoma, 614. 

tubo-ovarian, 601. 
rectum, 844. 
uterus, 394. 
urachus, 815. 

treatment, 815. 
vagina, 224; illus., p. 225. 
vulva, 223. 
vulvo-vaginal gland, 247. 

histology, 247. 

treatment, 249. 
Cystadenoma of, kidney, 782. 

ovary, 18, 621; illus., p. 662. 
Cystitis, 257. 
bacteria of, 791. 
definition, 790. 
diagnosis, 793. 
etiology, 790. 
pathologic changes, 792. 
pus from, 793. 
symptoms, 793. 
treatment, 794. 
urine in, 793. 
Cystocele, 238; illus., p. 238. 

operation for, 241; illus., p. 239. 
Cystoma, parovarian, 671. 
tubal, 480. 

origin, 480. 
Cystonephrosis, see Nephrocytosis. 
Cystoscope, illus., p. 748. 

use of, 749. 
Czerniewski, 52, 376. 
Czerny, 333, 447. 



INDEX 



873 



Da Costa, 727. 

Dartigues, 751. 

Daurios, 385. 

Davenport, 634. 

Davidsohn, 176. 

Davidson, 76. 

Davies, 100. 

Deaver, 528. 

Depaul, 463. 

Debility as a cause of menorrhagia, 714. 

Deeidua of etopic pregnancy, 656. 

Deciduoma malignum, see Syncytioma ma- 

lignuin. 
Deciduoma sarcoma, see Syncytioma ma- 
lignum. 
Delageniere, 114, 125, 281, 282, 305. 
Delbet, 682. 
Demme, 171. 
Deneaux, 137. 
Denuce, 797. 

Denudation for trachelorrhaphy, 339. 
Depas, 202. 

Dercum, 856, 858, 860, 862, 863, 864, 865. 
Dermoid cysts, 14, 611. 

contents, 611. 

histology, 611. 

malignant degeneration, 614; illus., p. 
614. 

origin, 613. 

of ovary, 67. 

rectum, 844. 

vagina, 225. 

vulva, 224. 
Descensus of ovary, 563. 

of uterus, 317. 
De Sinerty, 172, 711. 
Desplans, 692. 
Deutsch, 335. 

Development of genital organs, 117. 
Deviations from pathological laws, 12. 
Dewille, 520. 

Diabetes as a cause of pruritus vulvae, 204. 
Diagnosis, 29. 

curettage for, 364. 

digitation for, 364. 

scope, 29. 
Diaphragm, pelvic, 253, 284. 
Diarrhoea as a cause of rectal disease, 820. 
Dichotomy, posterior, 121. 
Dickinson, 253. 
Dietl, 759. 
Digital examination, 35. 

technique, 36. 
Digitation, exploratory, 364. 
Dilatation of cervix, 356, 364, 421. 

as a cause of infection, 362. 

electricity in, 730. 

for ante-deviations, 312. 

technique, 313. 
Dilatation of urethra, 803. 

causes, 803. 

operations for, 803. 
Dilator, as a means of examination, 45. 

Goodell's, 46; illus., p. 46. 

Hegar's, 369; illus., p, 369. 



Dilator, Reed's, 541; illus., p. 541. 

urethral; illus., p. 746. 
Diplococcus pneumoniae, 486. 

in Fallopian tubes, 486. 
Diphallus, 120, 121. 
Diphtheria, bacillus of, 167. 
Diphtheria of external genitalia, 179. 
diagnosis, 179. 
symptoms, 179. 
treatment, 179. 
Disease, Raynaud's, 196. 
hypertrophic and hyperplastic, of puden- 
dum, 213, 
Diseases of women, civilization as a fac- 
tor, 6. 
general etiology of, 5. 
Indian women, 6. 
prevalence, 5. 
systemic causes, 9. 
Disorders, pelvic, 865. 

nervous symptoms of, 865. 
Displacements of, Fallopian tubes, 473, 
477. 
kidneys, 750. 
ovaries, 560. 

causes, 564. 
rectum. 817. 
uterus, 284. 
ante-deviations, 310. 
bimanual examination of, 38. 
classification, 285. 
etiology, 285. 
inversion, 324. 
pathology of, 286. 
prolapse, 317. 
treatment, 288. 
vagina, 237. 
pathology, 238. 
symptoms, 238. 
treatment, 239. 
Distoma haematobium, infection, 180. 
Dittrich, 481. 
Diverticula of urethra, 801. 

treatment, 802. 
Divulsion of rectum, 846. 
Doderlein, 16, 164, 166, 170, 372, 490, 513, 

531. 
Doleris, 478, 546, 600. 

Doran, Alban, 422, 478, 628, 635, 670, 805. 
Dorsal position, 33; illus., 33. 
Dorsett, 255. 
Double uterus, 278. 

Douche, intrauterine, for hemostasis, 425. 
vaginal, 33. 
apparatus for, 32. 
in gonorrhoea, 169. 
infections of ovary, 581. 
malignant diseases, 236. 
pruritus, 204. 
salpingitis, 37, 535. 
Douglas, 204, 285, 314, 630, 805. 
Doyen, 81. 418, 528, 530, 554, 555, 556, 557, 

558, 559. 
Doyen's operation of hysterectomy, 556. 
modifications, 567. 



874 



A TEXT-BOOK OF GYNECOLOGY 



Doyen's operation of hysterectomy, Pry- 

or's modification, 558. 
Drainage, 112, 115, 116. 

abdominal incision, 112. 

abdominovaginal incision, 544. 

after, abdominal section, 114. 
hysterectomy, 414. 
myomectomy, 410. 
ovariotomy, 644. 
salpingectomy, 553; illus., 553, 554. 

exploratory incision for, 543. 

inguinal incision, 542. 

inguinal vaginal incision, 542. 

of pelvic abscess, 689. 

salpingitis, 540. 

through-and-through, 544, 545. 

tubercular peritonitis, 697. 

tube, Reed's, 114; illus., p. 115. 

Reed's through-and-through, 544; il- 
lus., p. 544. 

vaginal puncture, 542; illus., 542. 
Dranitzin, 123. 
Dressing, for abdominal incision, 470. 

sterilization of, 62. 
Dronius, 460. 
Drysdale, 606. 
Dsirne, 648. 
Dubois, 461. 
Ducrey, 183. 
Duct of Gartner, 671. 

of Miiller, 117, 118, 126. 

Wolffian, 671. 
Dudley, A. Palmer, 97, 265, 294, 682, 683. 

685. 
Dudley, E. C, 32, 219, 282, 314, 730. 
Duhrssen, 235, 437, 441. 
Dujon, 245. 
Duke, Alexander, 44. 
Dumesnil, 210. 
Dumont-Leloir, 365, 370. 
Dumont forceps, 370. 
Duncan, Matthews, 189, 429, 682, 726. 
Dunlap, 633, 638. 
Dunn, 588. 
Dunning, 425. 
Duplay, 606. 
Dupuytren, 725. 
Dwight, 682. 
Dysentery, 838. 

as a cause of stricture, 838. 
Dysmenorrhcea, 130, 360. 

as a symptom of salpingitis, 502. 

effect of corsets, 729. 

etiology, 725. 

exercise as a preventive, 729. 

medical treatment, 731. 

membranous, 752; illus., p. 732. 
causes, 732. 
symptoms, 733. 
treatment, 734. 

treatment of, 728. 
Dyspepsia as a cause of amenorrhcea, 722. 

Earle, 830. 

Ear, menstruation from, 736. 



Ebstein, 776. 

Ecchymosis in endometritis, 362. 
Echinococcous infection of, broad liga- 
ment, 690. 

uterus, 393. 
diagnosis, 394. 
hysterectomy for, 395. 
pregnancy in, 394. 
symptoms, 394. 
treatment, 395. 
Eckhard, 626. 

Ecraseur, application of, 424. 
Eckstein, 683. 

Ectopic pregnancy, see Pregnancy, ec- 
topic. 
Eczema intertrigo, 191. 
Eczema marginatum, 205. 
Eczema rubrum, 197. 
Eczema of vulva, 196. 

acute, 196. 

chronic, 197. 

treatment, 197. 
Edebohls, 313, 527, 695, 752. 
Education as a cause of disease in wom- 
en, 6. 
Edwards, W. A., 123, 844. 
Ehrendorfer, 229, 801. 
Eiselberg, 52. 
Elder, George, 122. 
Electric forceps, 84; illus., p. 84. 
Electricity, apparatus, 539. 

as a therapeutic, 23. 

for fibroid tumours, 124. 

for fibromyomata, 404. 

for hemostasis, 83. 

for menorrhagia, 719. 

for pruritus vulvae, 204. 

for salpingitis, 539. 

in dilatation of cervix, 730. 

in uterine dsplacements, 291. 

indications for use, 23. 
Electro-hemostasis, 83. 
Elephantiasis of vulva, 216. 

classification, 217. 

etiology, 219. 

histology, 218. 
Ellinger, 312. 
Eisner, 167, 179. 
Emanuel, 387. 
Emboli, 73. 
Embryology, of hymen, 131. 

of parovarium, 670. 

of vagina, 117. 
Emerich, 52. 

Emmet, 2, 4, 22, 144, 173, 262, 263, 267, 271, 
285, 306, 323, 324, 334, 339, 341, 342, 
349, 366, 391, 421, 422, 423, 725, 730, 
818. 
Emmet's operation for, incomplete lacera- 
tion of perineum, 260. 
modifications, 265. 

prolapsus, 323. 
Emotion, as cause of menorrhagia, 714. 
Enchondromata of, rectum, 844. 

vulva, 223. 



INDEX 



875 



Endocervix, eversion of, 335. 
Endometritis, 357; illus., p. 359. 

as cause of dysnienorrhoea, 360. 

cauterization in, 366. 

cervix in, 364. 

curettage for, 313, 368. 

diagnosis of, 364. 

discharge in, 363. 

ecchymosis in, 362. 

escharotics in, 365. 

etiology, 361, 362. 

exfoliative, 352. 

glands in, 363. 

hemorrhage in, 363. 

hot-water irrigation for, 367. 

hypertrophic, 361. 

packing for, 366. 

Reed's treatment, 365. 

section, illus., p. 352. 

steam treatment, 366. 

symptoms, 363. 

tampon for diagnosis, 363. 

topical remedies, 365. 

treatment, 365. 

tuberculous, 388. 
Endometrium, functiomof, 350. 

inflammation of, 357. 

in menstruation, 351. 

microscopic anatomy of, 350. 

secretion of, 350. 
Endothelioma of ovary, 624. 
histology, 625. 
recurrence of 626. 
section, illus., 625. 
types of, 625. 

uterus, 434. 
origin, 435. 

vagina, 233. 
Engelmann, 22, 23, 680. 
Engorgements of liver, as a cause of gen- 
ital disorders, 9. 
Enteroclysis, 77. 
Enucleation of myoma, 409. 

of uterine tumours, 420. 
technique. 421. 
Epispadias. 123; illus., p. 124. 

treatment, 123. 
Epistaxis. 127. 
Epithelioma, of cervix, 386. 

resemblance to tuberculosis, 387. 

clitoris. 228: illus., p. 229. 

kidney, 783. 
Epithelium of endometrium, 351. 
reproduction of, 370. 

of tubal mucosa, 489. 
hyperplasia of, 522. 
Eppinger, 429. 
Ernst, 718. 
Erosion, chancrous, 185. 

superficial, 185. 
Erysipelas, 52. 

as a cause of genital disorders, 9. 

of external genitalia, 177. 

symptoms of, 177. 

treatment of, 178. 



Erythema, etiology of, 194. 

treatment, 195. 
Escharotics, in endometritis, 365. 
Escherich, 791. 

Eskimo, menstruation of, 700. 
Esmarch, 24. 
Esmarch's chloroform inhaler, 94 ; illus., 

p. 95. 
Ether, administration of, 90, 92. 

contraindications for use, 90. 

indications for use of, 88. 

inhaler, 94. 

relation to bodily temperature, 89. 

relative safety of, 88. 
Etheridge, J. H., 446. 
Etiology of, diseases of women, 5. 

sterility, 141. 
Eversion of the endocervix, 335. 
Examination, of various parts of the 
body, 47. 

anaesthesia in, 40, 92. 

bimanual, 37; illus., p. 37. 

digital. 35. 

gynecological, 30. 

instrumental, 42. 

of blood, 49. 

of external genitals, 34. 

of faeces, 48. 

of Fallopian tubes, 516. 

of kidneys, 744. 

of inverted uterus, 326. 

of menstrual discharge, 48. 

of nervous system, 49. 

of ovary, 632. 

of prolapsus uteri, 321. 

of rectum, 808. 

of urinary apparatus, 744. 

of urine, 47. 

of uterine displacement, 290. 

physical, 31, 744. 

rectal, 39. 

vaginal, 30. 
Excision of clitoris. 234; illus.. p. 234, 235. 

of rectum, 847. 
Excrescence, masturbatory, 215. 
Exosmosis, 22. 

Exposure, as cause of shock. 72. 
External genitalia, 34. 

development. 117. 

diseases of skin, 191. 

examination. 34. 

hypertrophic and hyperplastic disease, 
213. 

infections of. 163. 

injuries of, 135. 
Extirpation of vagina, 235. 
Extract, of ovary, 21. 

suprarenal. 75. 

thyroid, 21. 
Extra-uterine pregnancy, see Ectopic 
pregnancy. 

Fackler, 186. 

Faeces, examination of, 48. 

Fainting, 73. 



876 



A TEXT-BOOK OF GYNECOLOGY 



Palconiis, Nicolai, 460. 

Falk, 22. 

Fallopian tubes, absence of, 473. 

accessory tubes, 474. 

actinomycosis, 231. 

anatomy, 489. 

anomalies of, as cause of ectopic preg- 
nancy, 651. 

atresia, cause, 495. 

bacillus coli, infection of, 528. 

bacillus tuberculosis in, 486. 

bacteria in disease, 484. 

bacteria in health, 484. 

carcinomata of, 48. 

chronic salpingitis, 489. 
morbid histology, 491. 

conservative operations in, 546. 

cystomata of, 480. 

development, 473. 

defective development, 473; illus., p. 
474. 

displacements, 473, 477. 

diplococcus pneumoniae in, 486. 

fibromyomata of, 481. 

gonococcous infection of, 512. 

hernia of, 477. 

hydrosalpinx, 484. 

infections of, 483, 512. 

infectiou, relative to inflammation of, 
487. 

irrigation, 584. 

ligation of, in Csesarean section, 469. 

lipomata of, 480. 

malformations, 473. 

manual examination of, 38. 

menstrual function of, 709. 

" mixed infection " of, 486. 

neoplasms, 478, 481. 

origin, 117. 

ostia, 474; illus., p. 475. 

papillomata of, 478. 

pneumococcous infection of, 529. 

pyosalpinx, 486. 

radical operations on, 549. 

salpingitis, acute, 489. 

salpingitis, catarrhal, 489. 

salpingitis, chronic, 486. 

saprophytic infection of, 530. 

sarcomata of, 482. 

section, salpingitis, illus., pp. 491, 492. 

septic vibrion infection, 531. 

staphylococcous infection of, 530. 

streptococcous infection of, 516. 

structure of mucosa, 489. 

supernumerary, 474. 

Tait's operation for removal of, 551. 

tuberculosis of, 519. 
Farmer, 463. 
Farnsworth, 436. 
Fat embolism, 73. 
Fat, subcutaneous, retraction of, 110, 113 : 

illus., p. 111. 
Fehleisen, 376. 
Fehling, 213, 376, 391, 606. 
Fehrenbatch, Colonel John, 61. 



Feinberg, 204. 

Fenger, 761, 764, 767. 

Ferguson, 307, 308. 

Ferguson's operation of ventral fixation, 

308; illus., p. 309. 
Fernet, 520. 

Fever, puerperal, 52, 376. 
bacteria of, 376. 
curettage in, 381. 
diagnosis, 381. 
endometrium in, 377. 
hysterectomy in, 383. 
irrigation in, 382. 
lochia in, 380. 
myometrium in, 377. 
pathology of, 376. 
perspiration in, 380. 
respiration in, 381. 
syphilis in, 376. 
symptoms, 380. 
tampon for, 382. 
temperature curve, 380. 
treatment, 381. 
Fibrocystoma, of uterus as a complication! 

of ovarian tumours, 636. 
Fibroid, recurrent, 435. 
Fibroid tumours of, broad ligament, 677. 
cervix, 420. 
Fallopian tubes, 480. 
kidney, 781. 
ovary, 614; illus., 615. 
rectum, 843; illus., 843. 
uterus, 396. 
vagina, 226. 
vulva, 222. 
Fibroma molluscum of vulva, 223. 
Fibromyomata, classification, 397. 

degeneration of, 299, 399; illus., 401. 
Fibromyomata of broad ligament, 677, 682. 
uterus, 396. 
diagnosis, 401. 
etiology, 397. 
hemorrhage, 401. 
histology of, 398. 
hysterectomy for, 404; illus., 405. 
interstitial, 398; illus., 402. 
intraligamentous, 398. 
pain, 401. 

pregnancy, 403; illus., 404. 
subserous, 398. 
treatment, 404. 
Fallopian tubes, 480. 

origin, 480. 
vulva, 18, 222. 
Filters, 61. 
Fimbria in streptococcous infection of 

tubes, 517. 
Fischel, W., 670, 671, 672, 673. 
Fischer, 245. 
Fischer, J., 21. 
Fissure, anal, 820. 
diagnosis, 833. 
symptoms, 832. 
treatment, 833. 
Fistula, faecal, 152, 831; illus., 151. 



INDEX 



8TT 



Fistula, faecal, diagnosis, 835. 

symptoms, 835. 

treatment, 835. 
Fistulae, urinary, illus., 344, 345. 

diagnosis of. 141. 

etiology of. 140. 

operations, 142, 155. 

prognosis, 142. 

symptoms, 141. 

treatment, 142. 

vesico-umbilical, 804. 
Fixation, ventral, of uterus. 305. 

vagina, 303. 
Flaischlen, 610, 626. 

Flap-splitting operation, 267: illus.. p. 201 
Flexner, 514. 
Floor, pelvic, 250. 
Florence solution, 158, 159. 
Foetal uterus, 277. 

menstruation from, 277. 

symptoms of, 277. 

treatment of, 277. 
Foetus, location of. 465. 

manipulation of. 407. 
Follicle, hair, 198. 
Follicular cysts of ovary, illus., p. 598. 

development of, 598. 

contents, 599. 

histology, 599. 
Folliculitis, 198. 

symptoms, 199. 

treatment, 199. 
Forceps, Bozeman's dressing, illus., 369. 

cervix. 370. 

dissecting, illus., p. 448, 639. 

electric (hemostasis), 84; illus.. p. 84. 

hemostatic, 80. 

hemostatic, application of, 107. 

mouse-toothed, illus., p. 747. 

Pean's, 423: illus., p. 422. 

pressure, illus., p. 640. 

Pryor's traction. 558. 

Reed's, for round ligament, 300. 

serrated cervix, 370. 

tongue, 95. 
Ford, 136. 
Fordyce, 129. 131. 
Foreign bodies in bladder, 796. 

in, uterus, 348. 
Formula, condylomata treatment, 216. 

erythema, treatment of. 195. 

intertrigo, treatment of. 193. 

leucorrhcea, treatment of. 374. 

resorcin salve, 194. 

Wilkinson's ointment, 194. 
Fornia, 185. 

Foster. Frank P.. 3. 50, 56. 100. 
Fourchette, see Yulva. 
Fournier. 161, 302. 
Francke, 441. 
Frank, 294, 757. 

Friinkel, 180, 386, 387, 599. 611. 
Franque, 386, 389, 432, 437, 575, 576. 
Freer, 805. 
Frerichs. 577. 



Freund, 21, 271, 304, 394, 458. 

Freund, TV*. A., 691. 

Freymuth. 166. 

Friedlander, 385, 175. 

Fritsch, 235, 241, 366, 556, 813. 

Froebel, 7. 

Frommel, 529, 530, 574, 575. 

Frorieps, 389. 

Fuller, 692. 

Function of cervix, 350. 

of endometrium. 351. 

of pelvic floor, 250, 254. 

of vulvo-vaginal gland, 243. 
Fused kidney, 751. 
Fiitterer, 758. 

Gaither, 382. 
Galen, 1. 
Ganghoffer, 440. 

Gant, 823, 825, 826, 830, 831, 832, 838, 840, 
. 841, 842, 843, 844, 845, 847, 848, 851, 
S52, 853. 
Gant's clamp, 854. 
Gardien, 460. 
Gardiner, 647. 
Gartner, 248. 
Gartner's duct. 671. 

cysts of. 224. 
Gau, 382. 
Gau's curette. 345; illus.. p. 346. 

speculum, 44; illus., p. 43. 
Gauze for drainage. 614. 
Gaylord. 184. 647. 
Gebhard. 13, 430, 434. 611. 
Gehle. 526. 
Gehrung, 726. 
Geil. 389. 
Geist, 249. 
Gemmell. 702. 
Generative organs in ovulation, 14. 

pathology. 12. 
Genital glands, 117. 

groove, 117. 

tubercle, 117. 
Genitalia, external, aerogenous infection 
of, 180. 

aphtha- of. 179. 

bacteriology of. 163. 

cutaneous diseases of, 191. 

development of. 117. 

diphtheria of, 179. 

erysipelas of. 178. 

gonorrhoea of. 53. 166. 

infection of. 163. 165. 

injuries of. 156. 

neoplastic changes. 18. 

parasites of skin. 205. 

syphilis of, 17, 189. 

trophic changes. 17. 

tuberculosis of, 17. 
Geraldes, 670. 
Germicidal agents, 63, 170. 
Gersuny, 123, 803. 

Gersuny's operation for dilatation of the 
urethra, 803. 



878 



A TEXT-BOOK OF GYNECOLOGY 



Gessner, 364. 

Gestation, relation to pathological states, 

14. 
Giglio, 531. 
Gilliam, 604. 
Girode, 528, 530. 

Glands, inguinal, suppuration of, 515. 
genital, 117. 

lymphatic, removal of, 452. 
sexual, 126. 

uterine, dilatation of, 361, 363. 
vulvo- vaginal, 170, 243; illus., p. 243. 
carcinoma of, 228. 
extirpation of, 170. 
gonorrhoea of, 167. 
Glans of clitoris, 118. 
Gleaves, 124, 783. 
Glenard's disease, 757. 
Gloves, rubber, 70, 295. 
Glycosuria, as a cause of erythema, 194. 

at menopause, 740. 
Goelet, 719. 
Geonner, 353. 
Goffe, 294, 301, 328, 681. 
Goglio, 387. 

Goldspohn, 68, 271, 298. 
Gonococcus, 53. 
as a cause of disease in women, 11. 
destructive action, 374. 
means of diagnosis, 373. 
of Neisser, 53, 163; illus., p. 53. 
superinfection with, 375. 
Gonococcous infection of, external geni- 
talia, 53, 166. 
course of, 166. 
diagnosis, 167. 
pathology, 167. 
treatment, 168. 
Fallopian tubes, 512. 
action of leucocytes, 513. 
bimanual examination in, 515. 
course of, 512. 
desquamation in, 513. 
discharge in, 515. 
fimbriae in, 513. 
location of gonococci, 513. 
pain in, 515. 
symptoms, 515. 
inguinal glands, 515. 
ovary, 569, 574. 
origin, 574. 
sclerosis in, 574. 
symptoms, 580. 
results, 580. 
rectum, 826. 
etiology, 826. 
pathology, 827. 
treatment, 827. 
Skene's glands, 245. 
uterus, 372. 
diagnosis, 373. 
etiology, 372. 
in puerperium, 373. 
pathology, 373. 
secretion in, 732. 



Gonococcous infection of uterus, symp- 
toms, 373. 
tampon for, 375. 
treatment, 374. 

vulvo-vaginal glands, 170. 
histology, 244. 
symptoms, 245. 
Gonorrhoea, see Gonococcous infection. 
Gonzalez, 588. 

Goodell, 9, 46, 429, 313, 730, 681. 
Gordon, S. C, 4. 
Gortier, 686. 
Gottschalk, 354, 627. 
Goulard, 196. 
Goulliund, 750. 
Goutil, 649. 

Graafian follicle, 13, 14. 
Gram, 183, 487, 513. 
Granicher, 232. 
Grape, 434. 

Grawitz, 115, 571, 785. 
Green, 473. 
Groove, genital, 117. 
Guerin, 224. 
Guilbert, 2. 
Guillemeau, 461. 
Guillemain, 576. 
Gummata, 688. 

of rectum, 829. 
Gunning, 734. 

Gusenthal, Von Rogner, 565. 
Gusserow, 436, 460, 696, 671. 
Guyon, 528, 765, 786. 
Gynandria, 126. 

Gynecological armamentarium, 27. 
Gynecology, conservative, 4. 

definition, 1. 

etymology, 1. 

examination in, 3. 

historical resume, 1. 

nomenclature, 3. 

radical, 4. 

specialism in, 2. 

therapeutics of, 20. 

Habits, personal, as a cause of pelvic dis- 
ease, 8. 
Haeckel, 230. 
Hages, 686. 
Hair follicle, 198. 

anatomy of, 198. 

infection of, 199. 
Halbertsma, 391. 
Hall, 676, 677. 
Halle, 791. 
Halstead, 70. 
Hammarsten, 603, 606. 
Handfield-Jones, 726, 727. 
Hands, sterilization of, 69. 
Hanks, 313, 403. 
Hannan, 442. 
Hare, 74, 88, 89, 93. 

Harris, M. L., 251, 253, 273, 474, 754, 758, 
761, 763, 764, 776, 777, 782, 789, 791, 
796, 818. 



INDEX 



879 



Harris, R. P., 100. 

Harris's operations for deep injuries of 
pelvic floor, 272. 

urine segregator, 747; illus., p. 748. 
Hart, 131. 

Hart, Berry, 126, 131. 
Hartrnan, 528. 
Hassmer, 725. 
Hauser, 792. 
Haussman, 163. 
Hawkins, 676, 677. 
Head, manipulation of, in anaesthesia, 96. 

in birth. 256. 
Heape, Walter, 699, 708, 710. 
Heat, hemostasis by, 80. 

sterilization by, 61. 

treatment of shock by, 75. 
Hebra, 205. 
Hecker, 137. 
Hegar, 385, 388, 427, 520, 521, 524, 525, 526, 

527, 578, 5S4, 597, 632, 680, 681. 
Hegar's dilator, 369. 
Heiberg, 627. 
Heidenhain, 205. 
Heil, 318. 
Heimbs, 389. 
Heineke, 761. 
Heinrichs, 623. 
Heitzmann, 210. 
Heller. 7G4. 

Hemangeiomata of pudendum, 221. 
Hematocele, pudendal, 135, 136, 137, 138. 

rupture of, 137. 

suppurating, 664. 
Hematocolpus, 119, 127, 130, 133; illus., 

p. 127. 
Hematoma of ovary, 618. 

diagnosis, 618. 

pathology. 618. 

pudendum. 137. 
Hematometra, 127, 133. 
Hematosalpinx, 127. 

etiology, 499. 

histology, 499. 
Hematuria, as a symptom of renal tu- 
mour, 786. 

renal tuberculosis, 774. 

vesical tumours, 799. 
Hemoptysis, 736. 
Hemorrhage, 73. 78. 

diagnosis of, 73. 

follicular, 61S. 

in lacerated cervix, 336. 

in rape, 157. 

in rupture of uterus, 535. 

intervillous, 654. 

interplacental, 654. 

symptoms, 78. 

tampon for, 215. 

treatment of, 79, 630. 

vulvar, 135. 
Hemorrhoids, capillary, 850. 

causes. S49. 

clamp-and-cautery operation for, 853. 

clamp for, illus., p. 854. 



Hemorrhoids, cutaneous, 849. 

external, 849. 

injection of, 851. 

internal, 850. 

ligation of, 852. 

symptoms, 849. 

thrombotic, 849. 

treatment, 849, 851. 

venous, 851. 

Whitehead's operation for, 852. 
Hemostasis, by, cautery, 80. 

electric forceps, 83. 

heat, 80. 

ligature, 86. 

pressure. 80. 

styptics. 79. 
Hennig, 124. 4S9. 
Henoch, 696. 
Henrotin, 430. 476, 655. 
Herbert. C. 244. 
Hereford, 436. 
Heresco, 682, 7S7. 
Herman, 180, 392, 780. 
Hermaphroditism, 121, 124. 

bilateral, 562. 

pseudo, 125. 

unilateral, 562. 
Hernia, inguinal, 29S. 

of Fallopian tube, 477. 

of ovary, 126, 564. 

post-operative, 104, 106. 
Herpes progenitalis. 200. 

diagnosis, 201. 

etiology.- 201. 

treatment, 202. 
Herzog, 13. 14. 15, 17, IS, 399, 400, 427, 
429. 433. 440. 476, 650, 651, 654, 656, 
658, 659, 660, 781, 782, 783. 
Heppner, 271, 562. 
Heterogeneity, 2. 
Hewitt, Graily. 311, 726. 
Hewitt's pessary, 311. 
Heyse. 590. 
Hildebrandt, 271. 697. 
Hippocrates, 1, 24, 437, 852. 
Hirschfeld, 7S1, 7S3. 
Hirst. 257. 
His. 427. 
Hislop. 394. 
Histology, of acute salpingitis, 4S9. 

adenocarcinoma, 620. 

atrophy of vulva, 209. 

calcareous tumours of ovary, 616. 

carcinoma uteri, 439. 

chronic salpingitis, 491. 

cysts of corpus luteum, 600. 

cj-sts of vulvo-vaginal glands, 247. 

dermoid cysts, 611. 

ectopic pregnancy, 616. 

endothelioma, 625. 

fibroma of ovary, 615. 

fibroma of uterus. 398. 

follicular cysts, 599. 

gonorrhoea, 166. 

hematosalpinx, 499. 



880 



A TEXT-BOOK QF GYNECOLOGY 



Histology, of hypernephromata, 785. 

medullary carcinoma, 619. 

melano-carcinoma, 231; illus., p. 231. 

ovarian abscess, 14. 

papilary cysts, 609. 

papilloma, 609. 

pseudo-cysts, 606. 

renal adenomata, 782. 

renal adenosarcomata, 783. 

renal sarcoma, 782. 

sarcoma of Fallopian tubes, 482. 

sarcoma of ovary, 682. 

sarcoma of kidney, 782. 

sarcoma of uterus, 433. 

sarcoma of vagina, 233. 

serous cysts, 608. 

syncytioma malignum, 427. 

syphilis of broad ligament, 690. 

tuberculous peritoneum, 692. 

tuberculous tubes, 521. 

tuberculous ovary, 576. 

tuberculous vagina, 172. 

tubo-ovarian cyst, 576. 
Hofbauer, 390. 
Hoffmann, 549. 
Hofmann, E. V., 157. 
Hofmeier, 351, 458. 
Hofmeister, 67, 68. 
Holder, 6. 

Holmes, Oliver Wendell, 87, 113, 178, 376. 
Horseshoe kidney, 751. 
Hottentot apron, 213. 
Howie, 703. 
Huguier, 189, 224. 
Hunter, 397. 

Hutchinson, Jonathan, 4. 
Hydatid of Morgagni, 671. 
ftyde, 189. 

Hydrocele of round ligament, pathology, 
677. 

treatment, 677. 
Hydronephrosis, see Nephrydrosis. 
Hydrosalpinx, calculus in, 497. 

definition, 495. 

diagnosis, 505, 510. 

discharge from, 505. 

distention in, 496. 

etiology, 484. 

menstrual disturbance from, 505. 

pain from, 505. 

pseudo-follicularis, 497. 

relation to pyosalpinx, 495. 

secretion in, 497. 

symptoms, 505. 

types, 497. 
Hydrops tubse profluens, 497. 
Hymen, absence of, 35, 133. 

anomalies of, 131, 133. 

atresia of, 132. 

biforis, 130. 

bilamellatus, 133. 

cysts of, 224. 

development of, 118. 

double, 133. 

embryology of, 131. 



Hymen, laceration of, 136, 157. 
malformations of, 131. 
operation on, for atresia, 133. 
puncture of, 725. 
Hyperaemia of bladder, 595. 
treatment, 796. 
ovary, 567. 
treatment, 568. 
Hyperesthesia, 861. 
Hypercatharsis, 101. 
Hypernephromata, 784; illus., p. 785. 

histology of, 785. 
Hyperplasia, of lymphatics, 688. 

pudendum, 213. 
Hypertrophy of cervix, 319. 
etiology, 335. 
clitoris, 126, 213. 
glands of uterus, 361. 
labia minora, 124, 213. 
ovaries, 
pathology, 594. 
treatment, 595. 
prepuce, 220. 

operation, 218, 219. 
pudendum, 213. 
uterus, 

treatment, 393. 
vulva, 213. 
Hypnosis, in anaesthesia, 98. 
Hypodermoclysis, 74, 76. 
Hypospadias, 118. 
operation for, 122; illus., p. 123. 
perineo-scrotal, 125; illus., p. 125. 
Hysterectomy, accidents in, 415. 
classification of, 405. 
complete, see Panhysterectomy, 
definition, 405. 
Doyen's, 556. 
electro, 456. 
advantages of, 457. 
definition, 456. 
results, 459. 
technique, 456. 
hemorrhage after, 415. 
supra-vaginal, 410. 
drainage aftei*, 414. 
hemostasis in, 411, 413. 
instruments for, 103, 412. 
technique, 412. 
vaginal, 419, 447. 
after-treatment, 452. 
angeiotribe in, 81. 
cautery in, 449. 
indications for, 559. 
instruments for, 103, 448. 
position of patient, 556. 
removal of ligatures, 452. 
technique, 448. 

technique, Doyen's operation, 556. 
treatment of adhesions, 557. 
treatment of glands, 453. 
Hysteria, 860. 

symptoms, 860. 
Hystero-myomectomy, see Myomectomy. 
Hysteroscope, 44; illus., p. 45. 



INDEX 



881 



Ichthyosis vulvae, 207. 
Ilio-coecygeus muscle, 251. 
Ill, 382, 805. 
Immerwahr, 354. 
Incision, exploratory, 637. 
Incision for, abdominal section, 

closure of, 109. 

direction of, 105. 

general observations on, 107. 

inguinal, 106. 

location of, 103. 

lumbocostal, 107. 

lumbo-iliac, 107. 

oblique subcostal, 106. 

oblique ventral, 107. 

transverse suprapubic, 106. 

transverse umbilical, 106. 

vertical median, 105. 
drainage, 

abdominal, 544, 689. 

abdominal vaginal, 544. 

dilator for, 541. 

inguinal, 542. 

inguino-vaginal, 542. 

rectal, 546. 

vaginal, 541. 
nephrectomy. 787. 
ovariotomy, 641. 
perineorrhaphy, 258. 
Incontinence of urine, 134, 141. 
Indian women, menstrual habits of, 6. 
Infantile uterus, 277. 

treatment, 280. 
Infantilism, 120. 
Infections, of, bladder, 
as a symptom of rape, 158. 
puerperal, 10, 18, 165. 
etiology, 178. 
Infections, of bladder, 790. 

bacteriology of, 791. 

diagnosis, 793. 

etiology, 790. 

pathology, 792. 

symptoms, 793. 

treatment, 794. 
"broad ligament, 688. 

course of, 163. 

etiology, 688. 

pathology, 688. 
external genitalia, 163. 

mixed, 165. 

course of, 163. 
Fallopian tubes, 483. 

course of, 532. 

douche in, 535. 

hygienic treatment, 535. 

liberation of pus, 534. 

local treatment, 537. 

massage for, 538. 

medicinal treatment, 536. 

prognosis, 533. 
' radical treatment, 549. 

relation to inflammation, 487. 

rupture in, 534. 

symptoms, 501. 

57 



Infections of Fallopian tubes, treatment, 
532. 

tampon for, 537. 
hair follicle, 199. 
kidneys, 768. 

bacteria of, 769. 

diagnosis, 770. 

etiology, 768. 

pathology, 770. 

treatment, 772. 

urination in, 771. 
lacerated cervix, 337. 
lymphatics, 392, 395. 
ovary, 567. 

conservative treatment, 582. 

mortality, 579. 

natural termination, 579. 

opium in, 581. 

radical treatment, 584. 

results of conservative treatment, 583. 

palliative treatment, 581. 

vaginal douche in, 581. 
peritoneum, 115, 688. 
pudendal hematocele, 136. 
rectum, 824. 

diagnosis, 824. 

prognosis, 825. 

results, 822. 

symptoms, 824. 

treatment, 825. 
uterus, 16, 350, 357, 372. 

endometrium in, 357. 

etiology, 362. 

mixed, 358. 

myometrium, 358. 

specific. 357. 

treatment, 365. 
vagina, 16, 163, 180. 
vulva. 163. 

vulvo-vaginal gland, 243, 248. 
Inflammation of, bladder, 790. 
Fallopian tubes, 487. 
ovary, 567. 
rectum, 424. 
uterus, 358. 
vagina, 163. 
vulva, 15, 153. 
vulvo-vaginal gland, 244. 
Infusion, intravenous, 77. 
subcutaneous, 76. 
rectal. 77. 
Inguinal hernia, 298. 

incision. 107. 
Inguinodynia, 862. 
Inhaler, 
chloroform, 94. 
ether. 92. 

mixed vapours, 94. 
Injection, 
cocaine. 97. 

treatment of hemorrhoids, 851. 
Injuries of, hymen, 157. 
pelvic floor. 253, 271. 
perineum, 162. 
rectum, 153. 



882 



A TEXT-BOOK OF GYNECOLOGY 



Injuries, of pudendum, 136. 

uterus, 162, 331. 

vagina, 135, 139. 

vulva, 135, 136, 157, 162. 
Instrumental examination, 42. 
Instruments for, abdominal section, 103. 

Csesarean section, 465. 

fistula operations, 145. 

ovariotomy, 639. 

perineorrhaphy, 259. 

supra-vaginal hysterectomy, 412. 

trachelorrhaphy, 338. 

vaginal hysterectomy, 448. 
Instruments, sterilization of, 66. 
Intercourse, sexual, injuries from, 136. 
Intercutaneous suture, 110; illus., p. 110. 
Intertrigo, vulvar, 191. 

diagnosis, 192. 

etiology, 191. 

pathology, 192. 

treatment, 193. 
Intravenous infusion, 77. 
Inversion of uterus, 324. 

acute, 327. 

chronic, 328. 

diagnosis, 326. 

etiology, 324. 

examination, 326. 

pathology, 327. 

surgical treatment, 329. 

symptoms, 326. 

tampon for, 329. 
Irion, 702. 
Irrigation, in gonorrhoea, 170. 

in puerperal fever, 382. 

of Fallopian tubes, 384. 
Israel, 764. 

Ischio-coccygeus muscle, 251. 
Ivanhoff, 25. 

Jacksch, 576. 

Jacobi, 781. 

Jacobs, 366, 458, 556, 576. 

Jacobson, 373. 

Jadassohn, 375. 

Jaennel, 819. 

Jaksch, 48. 

James, Alexander, 127. 

Jameson, 195. 

Jan, 119. 

Jani, 388, 520, 576. 

Janni, 683. 

Jans, 521, 692. 

Jenks, 21. 

Jevonsky, 209. 

Johnson, Joseph Taber, 641, 642, 644. 

Johnstone, A. W., 585. 

Jones, A. F., 327. 

Jones, George E., 313, 338, 382, 421, 425, 

433, 448. 
Jones, H. C, 721. 
Jones, Macnaughton, 308, 428, 736. 
Jones, Mary Dixon, 8. 
Jones's speculum, 370; illus., p. 370. 
Jonesco, 310. 



Jouin, 21. 
Jung, 233. 

Kahlden, 435, 
Kaltenbach, 680, 681. 
Kalustow, 233. 
Kangaroo tendon, 68. 
Karagan, 171, 172. 
Karewski, 163. 
Katz, 694. 
Kaufmann, 387. 
Keely, 779. 
Keen, 808. 

Kehrer, 163, 278, 329, 377. 
Keith, 80, 638, 680. 

Kelly, 171, 175, 241, 279, 306, 389, 391, 548^ 
611, 635, 671, 672, 678, 680, 694, 746, 
772, 779, 797. 
Kelynack, 781. 
Kerley, 737. 
Kholmogoroff, 204. 
Kidney, absence of, 749. 

adenomata of, 782. 

adenosarcoma of, 783. 

angeiomata of, 781. 

anomalies of form, 751. 
location, 750. 
numbers, 749. 

cystadenoma of, 782. 

epithelioma of, 783. 

examination of, 744. 

fibromata of, 781. 

fused, 751. 

horseshoe, 751. 

infections of, 768. 

lipomata, 781. 

movable, 752. 

operations on, 787. 

palpation of, 40. 

sarcoma of, 781. 

tuberculosis of, 772. 

tumours of, 780. 
Kiefer, 294. 
King, 538. 
Kirck, 330. 
Kisch, 739. 
Kitasato, 180. 
Kivisch, 480, 481, 525, 670. 
Klebs, 179, 495, 576, 609, 692. 
Klein, 233, 702. 
Kleinschmidt, 435. 
Klein wachter, 683, 733. 
Klob, 495, 678, 683. 
Klotz, 294. 
Knauer, 525. 

Knee-chest posture, 34, 291; illus., p. 34. 
Knife, Newman's, 339. 

canaliculus, 248. 
Knot, Staffordshire, 552. 
Kobelt, 670. 
Kobelt's tubes, 671. 

cyst of, illus., p. 475. 
Koch, 55. 172, 180, 697, 830. 
Kocher, 70, 105, 234. 
Koeberle, 2, 81, 306, 407, 638. 



INDEX 



883 



Kolisko, 232. 

Konig, 018, 787, 789. 

Kneftning, 183. 

Krajewski, 123. 

Kraska's operation, 848. 

Kraurosis vulvae, 207; illus., p. 208. 

diagnosis, 210. 

etiology, 208. 

histology, 209. 

macroscopic appearance, 207. 

treatment, 210. 
Kretschmer, 17. 
Krogius, 791, 792. 
Kronauer, 137. 
Kronig, 16, 70, 165, 373, 486. 
Kube, 475. 
Kuehne, 587, 658. 
Kumpf, 759. 

Kiister, 281, 282, 752, 754, 767. 
Kiistner, 318, 320. 
Kuttner, 753. 

Labadie-Lagrave, 518. 
Labia, adhesions of, 119, 120, 212. 
circulation of, 221. 
hypertrophy of, 213. 
malformations of, 124. 
neoplasms of, see Vulva. 
Lacassagne's schedule, 159. 
Laceration, of, cervix, 334. 

classification, 337. 

complication, 337. 

hemorrhage, 336. 

infection in, 337. 

operations for, 338. 

pathology of, 334. 

symptoms of, 335. 

treatment, 337. 
perineum, 253. 

classification, 255. 

complete, illus., p. 266. 
operations for, 267. 

Harris's operation for deep injuries. 
272. 

immediate operation for, 258. 

incomplete, 260. 
Emmet's operation, 260. 

Reed's suture, 263. 

prevention of, 256. 
La grippe, as cause of genital disorders, 9. 
Lair, 2. 

Laminated suture, 109. 
Landau, 497, 525, 558, 755, 763. 
Landon, 362. 
Langhans, 656. 
Lannelongue, 808. 

Laparotomy, see Abdominal section. 
Laser, 166. 
Lassar, 195. 
Lassar's paste, 200. 
Law of Metschnikoff, 60. 
Law of Wyssakovitsch, 60. 
Lawrence, 562, 708. 
Lawrie, 94, 95. 
Le Bee, 558. 



Lebedeff, 435. 

Le Cat, 120. 

Lebert, 385. 

Le Fort, 271. 

Legueu, 756. 

Leick, 179. 

Leiomyoma of broad ligament, 677. 

Lembert, 333. 

Lemhoff, 753. 

Leopold, 463, 624, 626, 638, 710. 

Lermoyez, 736. 

Lesion, tubercular, 172. 

anatomy of, 176. 
L'esthiomene, 171. 
Letulle, 797. 
Leucocytosis, 49. 
Leucoplakia, 228. 
Leucorrhoea, 176. 
Levator-ani muscle, 252, 253. 

restoration of, 271. 
Levret, 460. 
Levy, 180. 
Lewin, 201, 791. 
Lewis, 783. 

Libido sexualis after oophorectomy, 588. 
Liborius, 531. 

Ligament, broad, aneurismal varix of, 
682. 

cysts of, 67. 

infection of, 688. 

neoplasms of, 669. 

parasitic infection of, 690. 

phleboliths in, 682. 

pyogenic infection of, 682. 

suppuration in, 689. 

tuberculosis of, 691. 

varicocele of, 682. 
Ligament, round, dermoid tumours of. 
681. 

fibromyomata of, 682. 

hydrocele of, 677. 

in uterine displacements, 287. 

shortening of, 294. 
Alexander's operation, 294. 
Byford's operation, 302. 
Goffe's operation, 301. 
Mann's operation, 299. 
Ligature, catgut, 67. 

hemostasis with, 86. 

kangaroo tendon, 68. 

operation for hemorrhoids, 852. 

silk, 86. 

sterilization of, 66. 
Lipomata, of broad ligament, 677. 

Fallopian tubes, 480. 

kidney, 781. 

rectum, 842. 

vulva, 223. 
Lister, 2, 50, 67. 
Liszt, 255. 

Lithokelyphopaedion, 655. 
Lithokelyphos, 655. 
Lithopaedion, 655. 
Litten, 617. 
Lizars, 638. 



884 



A TEXT-BOOK OF GYNECOLOGY 



Lochia, bacteriology of, 166. 

Locke, 76. 

Lockett, 70. 

Loeffler, 179. 

Loewenthal, 706, 711. 

Lohlein, 289, 352. 

Lomer, 353. 

Loops, Pfluger's, 671. 

Lopez, 703. 

Lotion, Goulard's, 196. 

Louse, body, 206. 

Lubricant, for vaginal examination, 32. 

Ludwig, 332. 

Lumbocostal incision, 107. 

Lumbo-iliac incision, 107. 

Lupus vulvae, 171. 

Luschka, 814. 

Lusk, 331, 463, 470. 

Luther, 574. 

Lymphadenitis, 392, 690. 

Lymphangeiitis, 690. 

Lymphangeioma cystomatosum of ovary, 

624. 
Lymphangeiomata, 217. 
Lymphangeiosarcoma of ovary, 624. 
Lymphatics, hyperplasia of, 688. 

infection of, 377, 392, 395. 

uterine, 351. 
Lymphorrhoea, 219. 

Maas, 776. 

Macacus rhesus, menstruation of, 699. 

ovulation of, 710. 
Mackenzie, 392. 
Mackenrodt, 249, 304. 
MacNeven, 393, 394. 
Maculae, gonorrhoeae, 245. 
Madlener, 389, 378. 
Madleur, 373. 

Magill, 513, 517, 518, 528, 529, 530. 
Maier, 521. 

Malaria as a cause of menorrhagia, 714. 
Male, hypospadiac, 125. 
Malformations of anus, 806. 

clitoris, 124. 

Fallopian tubes, 473. 

hymen, 131. 

kidney, 749. 

labia, 124. 

ovary, 560. 

rectum, 124. 
prognosis, 807. 
symptoms, 807. 
varieties, 806. 

round ligament, 298. 

ureters, 760. 

uterus, classification, 274. 
etiology, 275. 
treatment, 280. 

vagina, 126. 

vestibular band, 134. 

vulva, 118. 
Malins, E., 683, 685. 
Malpighian layer, 215. 
Malthus, 10. 



Mandl, 13. 

Mann, 288, 289, 297, 299, 300, 301, 303, 304, 

306, 314, 324, 429, 564, 678. 
Mansfield, 460. 
Manton, 721. 
Marchand, 187, 428, 610. 
Marshall, Balfour, 230. 

Martin, A., 114, 148, 211, 249, 257, 271, 304, 
366, 368, 441, 480, 482, 493, 495, 499, 
524, 525, 526, 570, 575, 578, 583, 589, 
638, 680, 681, 781, 810, 811, 812, 835. 
Martin, Christopher, 126, 706, 738. 
Martin's curette, 368. 
Massage, abdominal, 24. 

pelvic, 25, 538. 

position of patient, 538. 

technique, 538. 

treatment of uterine displacement, 291. 

treatment of movable kidney, 759. 
Massen, 476. 
Massey, 726. 
Massin, 362. 
Masturbation, as cause of disease, 9. 

etiology, 212. 

evidences of, 160. 

excrescences from, 215. 

labia minora in, 35. 
Matas, 807, 808. 
Matthews, 97, 386, 854. 
Mauriceau, 460, 461. 
Mayer, W., 432, 521. 
McDowell, Ephraim, 2, 638, 639. 
McFarland, 434. 
McLaury, 703. 
McMurrick, 751. 
McMurtry, L. S., 263, 351, 403, 458, 663, 

666. 
Meadows, 749. 
Meatus urinarius, 230. 

melanosarcoma of, 230. 
Mechanism of prolapsus uteri, 318. 
Medication, general, 20. 

local, 22. 
Melano-carcinoma of vulva, 231. 
Melanosarcoma of vulva, 229. 

histology of, 231. 

of meatus urinarius, 230. 
Melchoir, 791, 792. 
Melier, 2. 

Membrane, uterine, reproduction of, 370. 
Menciere, 565, 566. 
Menge, 16, 353, 354, 487, 490, 495, 496, 521, 

530, 684, 685, 686, 687. 
Menopause, 203. 

age of occurrence, 738. 

carcinoma at, 740. 

effect on heart, 740. 
on ovaries, 738. 
on uterus, 738. 

glycosuria at, 740. 

inducement of, 584. 

mental condition at, 741. 

metrorrhagia at, 739. 

oophorectomy at, 587. 

tachycardia at, 740. 



INDEX 



885 



Menopause, treatment of associated con- 
ditions, 742. 
Menorrhagia, causes, 714. 
complications, 717. 
definition, 714. 
local causes, 714. 
pelvic causes, 715. 
rectal complications, 717. 
systemic causes, 714. 
tampon for, 716. 
treatment, 537, 716. 
uterus in, 715. 
Menses, cessation of, 738. 
examination of, 48. 
retention of, 282, 723. 
suppression of, 706. 
symptoms of retention, 723. 
Menstruation, absence of, 720. 
arrest of, 585. 
character of discharge, 705. 
cycle of, 704. 
disorders of, 714. 
disturbances of, 764. 
effect of general systemic diseases, 714. 
endometrium in, 351. 
Fallopian tubes in, 709. 
from, bicornate uterus, 278. 

cervix, 735. 

ear, 736. 

infantile uterus, 280. 

naevus, 737. 

nose, 736. 

septate uterus, 277. 

stomach, 736. 
hygiene of, 712. 
in atrophy of ovaries, 593. 
in cirrhosis of ovaries, 593. 
inducing cause, 706. 

ectopic pregnancy, 661. 

ovarian disease, 632. 

tubal tuberculosis, 526. 
normal, 699. 
of, domestic animals. 699. 

Eskimo, 700. 

Indian women, 6. 

Macacus rhesus, 699. 

savages, 699. 

Semnopithecus, 699. 

students, 8. 
ovaries in, 709. 
pain in. 725. 
persistence of, 588. 
precocious, 701. 
profuse, 719. 

quantity of discharge, 704. 
relation to, conception, 711. 

ovulation, 710. 

pathological state, 12. 
time of appearance, 701. 
uterus in, 13, 708. 
vicarious, 735. 
white, 705. 
Mesenteric cysts, 635. 

Metabolism, effect on oophorectomy, 589. 
Metastasis, 231, 621. 



Metastasis, causes, 610. 
from carcinoma uteri, 481. 

from syncytioma malignum, 429. 
Metritis, 358. 

as a cause of dysmenorrboea, 727. 

as a cause of menorrhagia, 715. 

classification, 358. 

diagnosis, 364. 

pathology, 359. 

Reed's method of treatment, 365. 

symptoms, 363. 

treatment, 365. 
Metrorrhagia, as a symptom of carcinoma, 
720. 

at menopause, 729. 

etiology, 719. 

treatment, 720. 
Metrostaxis, post-operative, 587. 
Metschnikoff, 60. 
Meyer, 253, 391. 
Micrococcus gonorrhoeae, 52. 
Mikulicz, 70, 83, 761. 
Miller, 44. 

Millikin, Dan, 699, 702, 704, 705, 706. 
Miner, 680. 
Minor, 643. 

Mirror, proctoscopic, 815. 
Mitchell, H. W„ 720. 
Mittelschmerz, 277. 
Mittermaier, 349. 

Mixed vapours for anaesthesia, 93. 
Molluscum pendulum of vulva, 223. 
Monclaire, 458. 
Montgomery, 257, 647. 
Monti, 178, 376. 
Moostakoff, 120. 
Morax, 513, 528, 530. 
Morcellement, forceps for, 423. 

hemorrhage in, 423. 

Pean's method, 423. 

technique, 422. 

treatment of pedicle, 422. 

uterine tumours, 420. 
Morgagni, 594. 

hydatid of, 671. 
Morris, 211, 212, 695. 
Morse, 783. 
Mosetig, von, 24. 
Mosler, 521, 575, 692. 
Mouth gag, 95. 
Movable kidney, 752. 

adhesions of, 757. 

as a cause of nephrydrosis, 763. 

etiology, 752. 

examination of, 752. 

gastric symptoms, 758. 

indications for operation, 760. 

massage for, 759. 

mechanical influences, 754. 

operations for, 760. 

pain in, 758. 

pathologic anatomy of, 755. 

supporter for, 759. 

treatment, palliative, 759. 
Movement of uterus, 285. 



886 



A TEXT-BOOK OF GYNECOLOGY 



Mucosa, tubal, in streptococcic infection, 
517. 

in tuberculosis, 524. 

structure of, 489. 
Mucosa, uterine, in endometritis, 362. 

tuberculosis, 389. 
Miiller, 9, 131, 230, 235, 303, 362, 476, 556, 

779. 
Miillerian vagina, 126, 127. 
Muller's duct, 117, 118. 
Munchmeier, 458. 
Munde, 257, 366, 647, 678, 679, 734. 
Miinster, 525. 
Muret, 130. 
Muscatello, 115. 
Muscles of pelvic floor, 250. 
Museux, 421. 
Myomata of bladder, 799. 

broad ligament, 677. 

rectum, 844. 

uterus, 396, 503. 

vulva, 222. 
Myomectomy, 404, 407. 

definition, 404. 

drainage after, 410. 

indications, 407. 

pregnancy after, 408. 

technique, 407. 

treatment of pedicle, 407. 
Myometrium, 

inflammation of, 358. 

in puerperal fever, 377. 

microscopic anatomy of, 352. 
Myomotomy, vaginal, 420. 
Myxomata of vulva, 223. 
Myxosarcoma of vulva, 229. 

Naegele, 710. 
Nagel, 126, 561, 599. 
Napheys, 6. 
Napier, 707, 738. 
Necrosis, 110. 
Needle, aneurismal, 452. 
holder, 450 
Holmes's, 113. 
Reed's curved, 339. 
Neisser, 53, 165, 167, 373, 374, 827, 166. 
Neisser, gonococcus of, 53. 
Neoplasms of, bladder, 798. 

diagnosis of, 799. 

symptoms of, 799. 

treatment, 800. 
broad ligament, carcinoina, 686. 

cysts, 670. 

dermoids, 6. 

fibromata, 677. 

lipomata, 677. 

myomata, 677. 

sarcoma, 686. 
Fallopian tubes, 478. 

adenosarcomata, 783. 

carcinoma, 481. 

cystomata, 480. 

fibromyomata, 481. 

lipomata, 480. 



Neoplasms > of Fallopian tubes, papillo- 
mata, 478. 
sarcoma, 482. 
kidneys, 780. 
diagnosis, 785. 
fibromata, 781. 
hypernephromata, 784. 
involvement of ureter, 786. 
pain from, 786. 
sarcoma, 781. 
symptoms, 785. 
treatment, 787. 
ovary, benign cysts, 597. 
bimanual examination of, 632. 
carcinoma, 619. 
complications of, 627. 

adhesions, 631. 

albuminuria, 631. 

ascites, 630, 635. 

echinococcous cyst, 635. 

fibrocystoma of uterus, 636. 

mesenteric cysts, 635. 

nephrydrosis, 635. 

phantom tumour, 636. 

pregnancy, 627, 634. 

rupture of tumour, 631. 

torsion of pedicle, 628. 
cysto-adenoma, 18. 
diagnosis, 633. 
effect on menstruation, 632. 
endothelioma, 624. 
hematoma, 618. 
palpation of, 633. 
sarcoma, 622. 
solid tumours, 614. 
symptoms, 503, 632. 
treatment, 637. 
pudendum, benign, 221. 
carcinomata, 227. 
enchondromata, 223. 
fibromata, 222. 
fibromyomata, 18. 
lipomata, 223. 
malignant, 221, 227. 
melano-carcinomata, 321. 
myomata, 222. 
myxomata, 223. 
sarcoma, 230. 
sarcomata, 229. 
treatment, 233. 
varices, 221. 
uterus, adenoma, 429. 
benign, 397. 
carcinoma, 437. 
etiology, 396. 
fibromyomata, 326. 
malignant, 426. 
sarcomata, 432. 
syncytioma malignum, 426. 
urethra, carcinoma, 801. 
caruncle, 80. 
melanosarcoma, 230. 
sarcoma, 801. 
vagina, benign, 224. 
carcinomata, 233. 



INDEX 



887 



Neoplasms, of vagina, cysts, 224. 
fibromata, 226. 
malignant, 231. 
polypi, 226. 
sarcomata, 231. 
treatment, 226. 

vulva, see Neoplasms of pudendum. 

vulvo-vaginal gland, 247. 
carcinoma, 249. 
cysts, 247. 
treatment, 248. 
Neoplastic changes in genitalia, 18. 
Nephrectomy, 767. 

clamp for, 789. 

technique, 789. 

treatment of pedicle, 789. 

treatment of ureter, 789. 
Nephritis, as a cause of menorrhagia, 714. 
Nephrocystosis, definition, 762. 

classification, 762. 
Nephropexy, technique, 788. 
Nephropyelitis, 768. 
Nephropyosis, 766, 768. 
Nephrorrhaphy, 788. 
Nephrotomy, 767. 

hemorrhage in, 788. 

technique, 788. 
Nephrydrosis, acquired, 763. 

as a complication of ovarian tumour, 
635. 

aspiration in, 767. 

causes of, 762. 

congenital, 762. 

diagnosis of, 765. 

intermittent, 765. 

nephrectomy for, 767. 

nephrotomy for, 767. 

partial, 764. 

pathological changes, 763. 

symptoms, 765. 

treatment, 766. 
Nerve derangements, 120. 
Nervous complicatious in gynecology, 856. 
Nervous symptoms of pelvic disorders, 

865. 
Nervous system, examination of, 49. 
Netter, 51. 

Neugebauer, 120, 133, 224, 329, 348. 
Neuralgia of rectum, 820. 
Neurasthenia, 856. 

as a cause of genital disorders, 9. 

symptoms, 856. 
Neuromata of vulva, 223. 
Neuroses, from oophoritis, 580. 

operations for, 864. 
Neurosis, fatigue, 856. 
Newman, 339, 849. 
Newman's angeiotribe, 81. 

volsella, 338. 
Nicolle, 513, 529. 
Nidus perinsei, 251. 
Niefer, Jacob, 460. 
Nietert, 346. 
Nitze, 747. 
Noble, George H., 443, 444. 



Nodule, indurated, 186. 

Noeggerath, 2, 11, 166. 

Xolen, 608. 

Noma of vulva, 167. 

Nomenclature, of gynecology, 3. 

Normal salt solution, 74, 75. 

Nose, menstruation from, 736. 

Nott, 365. 

Nott's speculum, 44. 

Nourse, 282. 

Nuck, 298, 564, 677. 

Numa, 175, 183. 

Nurse, requirements of, 63. 

Nussbaum, 67. 

Nuttall, 54, 180. 

Nymphsc, see Vulva. 

Obolonsky, 562. 

Obturator coccygeus muscle, 250. 
Occlusion of cervical canal, 279. 
Occupation, as a cause of disease, 8. 

rectal disease, 821. 

uterine displacement, 286. 
CEdema of vulva, 195. 

treatment, 196. 
Ohmann, 210. 
Oidium albicans, 167. 
Ointment, Wilkinson's, 194. 

Wilson's, 193, 200. 
Oligochromsemia, 49. 
Oliver, 429. 

Olshausen, 209, 235, 458, 482, 598, 611, 624, 
647, 648, 671, 672, 673, 674, 676, 679, 
680, 681, 763. 
Omentum, adhesions of, 642. 

laceration of, 643. 

tuberculosis of, 693. 
Oneida community, 9. 
Oophorectomy, 584. 

effect on, constitutional condition, 587. 
general metabolism, 589. 
intrapelvic conditions, 590. 
libido sexualis, 588. 
menopause, 587. 
menstruation, 587. 
sexual function, 587. 

history, 584. 

indications, 584. 

manipulation of tubes, 585. 

metrostaxis after, 587. 

mortality, 586. 

secondary effects, 587. 

technique, 585. 

treatment of pedicle, 585. 

unilateral, 585. 
Oophoritis, acute, 568. 

as cause of dysmenorrhcea, 728. 

chronic, 569. 

etiology, 569. 

histology, 569, 580. 

tuberculous, 575. 
Operating room, 64. 
Operating table, improvised, 64. 
Opium, in infection of ovary, 581. 
Oppenheim, 176. 



888 



A TEXT-BOOK OF GYNECOLOGY 



Orgasm, sexual, in bimanual examination, 

39. 
Orthmann, 209, 210, 303, 304, 478, 481, 525, 

600. 
Os, pin-hole, 283. 
Osiander, 447. 
Osier, 327, 692, 696. 
Osteomalacia, 590. 
Ostia, accessory, 474. 

relation to ectopic pregnancy, 476. 
Otroschkevitch, 739. 
Ott, 435, 707. 
Ovarian abscess, histology, 514. 

bacteriology, 514. 
Ovarian extract, 21. 
Ovariotomy, 638. 

abdominal incision, 641. 

accidents in, 646. 

after-treatment, 645. 

closure of incision, 644. 

drainage after, 644. 

dressing, 644. 

during pregnancy, 647. 

emptying of cyst, 641. 

history, 638. 

incomplete, 646. 

indications, 639. 

instruments, 639. 

ligature material, 642. 

mortality from, 646. 

peritoneal incision, 641. 

protection of intestines, illus., p. 108. 

technique, 639. 

toilet of peritoneum, 643. 

treatment of adhesions, 642. 

treatment of pedicle, 642. 
Ovary, absence of, 560. 

accessory, 561. 

at menopause, 738. 

atrophy of, 592. 

bacillus coli infection of, 575. 

bacteria of, 570. 

bimanual examination of, 38. 

calcification in, 617. 

cirrhosis of, 593. 

coexistence with testicles, 562. 

conservative operation on, 582. 

constricted, 561. 

cysts of, 597. 

development of, 117. 

displacement of, 560, 563. 

effects of removal, 586. 

gonococcous infection of, 574. 

hematoma of, 618. 

hernia of, 126, 564. 

hypersemia of, 567. 

hypertrophy of, 594. 

individual infections of, 571. 

infections of, 567. 

inflammation of, 567. 

in myomectomy, 407. 

malformations of, 560. 

menstrual function of, 709. 

neoplasms, malignant, 619. 

neoplasms of, 597. 



Ovary, papilloma of, 608. 

pneumococcous infection, 574_ 

prolapse of, 553. 

psammoma of, 621. 

radical operations on, 584. 

rudimentary, 
etiology, 561. 
diagnosis, 561. 
frequency, 560. 

treatment of infections, 581.. 

trophic diseases of, 592. 

tuberculosis of, 575. 

unilateral removal of, 585. 
Ovulation, 710. 

dangers of, 14. 

in Macacus rhesus, 710. 

pathological states, 13. 

relation to menstruation, 710.. 

Semnopithecus, 710. 
Ovum, impregnation of, 650. 
Oxygen in anaesthesia, 93. 

Pacinian corpuscle, 203. 

Pack, dry, 83. 

Packer, vaginal, 450. 

Paederasty, 821. 

Pain, as a symptom of, adhesions, 631. 

cirrhosis, 591. 

ectopic pregnancy, 661. 

hematoma of ovary, 618. 

hemorrhage, 78. 

hydrosalpinx, 505. 

nbromyomata, 401. 

movable kidney, 758. 

ovarian neoplasms, 632. 

pyosalpinx, 506, 509. 

renal calculi, 778. 

renal neoplasms, 786. 

salpingitis, 501, 535. 

torsion of tumour pedicle, 628. 

tubal tuberculosis, 526. 

tubercular 1 peritonitis, 694. 
Pain, intermenstrual, etiology, 734, 

pathology, 735. 

treatment, 735. 
Pain, menstrual, 725. 
Pajot, 470. 

Palmer, C. D., 313, 364, 680, 734. 
Palmer's dilator, 364. 
Palpation, abdominal, 40. 

of Fallopian tubes, 516. 

of kidney, 40. 
Panhysterectomy, abdominal, 415: illus., 
p. 416. 

advantages, 419. 

angeiotribe in, 418. 

electric clamp in, 419. 

hemostasis in, 417. 

Reed's operation, 417. 

results, 555. 

specimen, illus., pp. 418, 420. 

technique, 415. 
Panhysterectomy, abdomino-vaginal, 453. 

indications, 453. 
Paoli, 171, 175. 



INDEX 



889 



Papillae in condylomata, 214. 
Papillary cyst, 607. 
development, 607. 
Papilloma, of, bladder, 798. 
Fallopian tubes, 478. 
histology, 479. 
origin, 478. 
rupture of, 480. 
symptoms of. 4S0. 
treatment, 480. 
ovary, 608. 
histogensis, 609. 
histology, 608. 
rectum, causes, 843. 
treatment, 843. 
Paquelin. 349. 
Paquelin's cautery, 80. 
Paralysis of uterine wall, 325. 
Parasites of external genitalia, 205. 
Phtheirius inguinalis, 206. 
Trichophyton tonsurans, 205. 
Pare, 461. 

Park. Roswell, 437. 442. 
Parker. Rushton, 392, 593, 707. 
Parks, 736. 
Paroophoron. 671. 

cysts of. 671. 
Parovarium, anatomy, 670. 
embryology, 670. 
neoplasms of, 669. 
Parry. 649. 
Parsons, A., 706. 
Parturition, injuries from, 136. 
Parvin, 649. 
Passet, 55. 
Paste, Lassar's 200. 
Pasteur, 50, 61, 531. 
Patches, mucous, 187. 

treatment, 188. 
Pathologic laws, deviations from. 12. 
Pathologic states, due to gestation. 14. 
menstruation. 12. 
ovulation. 13. 
Pathology of. atrophy of ovaries. 593. 
vulva. 209. 
displacements of. Fallopian tubes. 47.°.. 
ovaries, 560. 
rectum. '818. 
uterus, 286. 
vagina, 238. 
female generative organs. 12. 
infections of, bladder, 792. 
broad ligament, 6S8. 
external genitalia. 163. 
Fallopian tubes, 4S9. 
ovary. 571. 
uterus. 359. 
inversion of uterus, 327. 
laceration of cervix, 334. 
prolapsus uteri, 319. 
pruritus vulvae, 203. 
puerperal fever, 376. 
shock. 72. 
Patient, preparation for operation. 412. 
for Caesarean section. 465. 



Patient, sterilization of, 66. 
Paul, of .Egina, 1. 
Paul, 70 

Pawlick, 635, 746. 767, 800. 
Pean, 81, 380, 385, 386, 544, 557, 638. 
Pean's forceps, 422. 
Peaslee, 144, 269, 312, 638. 
Pedicle, extra-peritoneal treatment of, 
414. 

ligation of, in ovariotomy, 642. 

torsion of, 629. 

treatment in myomectomy, 407. 
Pediculi pubis, 206. 

treatment, 206. 
Pelvic diaphragm, 2S4. 
Pelvic diseases and nervous affections,. 

856. 
Pelvic floor, anatomy of, 250. 

deep injuries, 271. 

function of, 250. 

injuries, 253. 

muscles of, 250. 

restoration of, 258. 
Pelvic massage, 25. 

varicocele, 6S4. 
Pelvis, measurement of. 464. 

suppuration in, 165, 689. 
Penis, imperforate, 125. 
Peraire. 391. 

Percussion of abdomen. 40. 
Perimetritis. 575. 
Perineorrhaphy, 258. 

Emmet's operation, 260. 

immediate operation, 258. 

instruments for, 259. 

posture for, 260. 

Reed's operation. 263. 

Tait's operation. 267. 
Perineo-scrotal hypospadias. 125. 
Perineum, definition, 251. 

function of. 254. 

injuries of, 162. 

laceration of. 253. 

malformations of. 124. 

preservation of. 256. 

syphilitic ulcers of, 189. 
Perioophoritis. 567. 
Periproctitis, causes, 826. 

treatment. 820. 
Peritoneum, incision of. 108. 

infection of. 115. 688. 

toilet of. in salpingectomy. 553. 
in ovariotomy, 643. 

tuberculosis of, 692. 
Peritonitis. 116. 

puerperal, 3S0. 
Pessary. 240. 

danger of, 362. 

gauze, 305. 

in Caesarean section, 467. 

in treatment of uterine displacement^ 
311. 322. 393. 

medicinal. 144. 
Pestalozzi. 7. 
Peters. 427. 657, 658. 



890 



A TEXT-BOOK OF GYNECOLOGY 



Petit. Paul, 600, 685, 721. 

Pfahler, 70. 

Pfannenstiel, 603, 606, 607, 609, 610, 611, 

620, 622. 
Pfeiffer, 201. 
Pfister, 587, 588, 589. 
Pfliiger, 609, 710. 
Pfliiger's loops, 671. 
Physical examination, 31. 
Physique of women, 5. 

of Indian women, 6. 
Pichevin, 366. 
Pick, 373, 434, 436, 625. 
Picque, 458. 
Pilliet, 600. 
Pincus, 367. 
Pirmer, 521. 
Placenta, location of, 466. 

location of, in ectopic pregnancy, 666. 

removal of. in Csesarean section, 468. 
Placentoma malignum, see Syncytioma 

malignum. 
Phleboliths of broad ligament, 682. 
Plethora, as a cause of menorrhagia, 

714. 
Pliny, 460. 
Plumb, 702. 

Pneumococeous infection of Fallopian 
tubes, etiology, 529. 

course of infection, 529. 

symptoms, 529. 
Pneumococeous infection of ovaries, 574. 

pus in, 575. 

treatment, 582. 
Poise of uterus, 15. 
Poisoning, septic, 73. 
Polk, 21, 294, 369. 
Polypus, rectal, 841. 

uterine, 424. 
extirpation of, 424. 
hemorrhage from, 425. 

vaginal, 226. 

vulvar, 219. 
Pomorski, 626. 
Pompilius, 460. 
Porro, 335. 
Porro's operation, 465. 

indications, 471. 

technique, 472. 
Portio vaginalis, carcinoma of, 438. 
Position, normal, of uterus, 285. 
Posner, 791. 

Post-operative antisepsis, 68. 
Posture, dorsal, 33; illus., p. 33. 

for examination of uterine displace- 
ments, 290; illus., p. 290. 

for perineorrhaphy, 260; illus., p. 262. 

knee-chest, 34; illus., p. 34. 

Sims's, 42: illus., p. 43. 

standing, 35; illus., p. 35. 

Trendelenburg, 454; illus., p. 454. 
Potter, 7, 32, 647. 
Poupinel, 225. 
Powder, dusting, 196. 
Powell, 826. 



Pozzi, 131, 171, 218, 240, 282, 358, 368, 390, 

391, 440, 521, 635, 647, 679. 
Precocity in development of vulva, men- 
strual, 701. 
Pregnancy, after, conservative operation 
on ovary, 583. 
myomectomy, 408. 
rupture of uterus, 334. 

complicating carcinoma, 443. 
ovarian tumours, 627, 634. 

echinococcous infection in, 394. 

gonorrhoea in, 375. 

ovariotomy in, 647. 

rape in, 158. 

tuberculosis in, 389. 
Pregnancy, ectopic, 15. 

abortion in, 655. 

action of syncytium, 655. 

ampullar, 652. 

capsularis in, 658. 

changes in muscularis, 659. 

classification, 652. 

course, 654. 

decidua in, 656. 

definition, 650. 

diagnosis, 662. 

etiology, 650. 

histology, 656. 

history, 649. 

interstitial, 652. 

intervillous space in, 659. 

instruments for, 103. 

isthmic tubal, 652. 

menstrual changes, 661. 

mortality, 665. 

operation, 665. 

pain in, 661. 

placental site, 666. 

rupture of, 654, 661. 

symptoms, 660. 

termination, 654. 

treatment, 664. 

treatment of sac, 666. 

tubo-abdominal, 653. 

tubo-ovarian, 653. 

tubo-uterine, 652. 

vaginal examination of, 662. 
Pregnancy, ovarian, illus., pp. 653, 654. 
Prepuce, adhesions of, 120, 211. 

hypertrophy of, 220. 

operations on, 218. 
Pressure, as a hemostatic, 80. 
Preuschen, 224. 
Prevention of conception as cause of 

genital disorders. 10. 
Price, Joseph, 403, 552, 653, 703. 
Priestley, 734. 
Prochownick, 671. 
Procidentia after colostomy, 847. 
Proctitis, 820. 
Proctoscope, 812. 

use of, 815. 
Proctoscopy, instrumental, chair for, 811. 
instruments, 812. 
postures for, 813. 



INDEX 



891 



Proctoscopy, instrumental, technique. 
813. 
noninstrumental, technique, SOS. 
Proctotomy, internal, 840. 
external, S40. 
posterior, S46. 
Prolapse of, ovary, 563. 
diagnosis, 564. 
symptoms, 564. 
treatment. 564. 
rectum, 820. 
causes, SIS. 
colotomy for. S20. 
symptoms, 819. 
treatment, 819. 
urethra, 
causes, 802. 
treatment, 802. 
uterus, 161, 275. 317; illus., p. 317. 
congenital, 279. 
diagnosis, 321. 
hygienic treatment, 322. 
infection in. 362. 
mechanical treatment, 318. 
mechanism of. 318. 
medicinal treatment. 321. 
pathologic changes, 319. 
pessary for. 322. 
symptoms, 321. 
tampon for, 322. 
vagina. 237. 
etiology. 23S. 
Prolegomena. 1. 

Proliferating cysts, classification, 602. 
contents, 603. 
histology, 603. 
Prophylaxis. 25S. 
Prostitutes, 9. 
chancroid in, 182. 
gonorrrhoea in, 166. 
herpes in, 2S1. 
Protonuclein, 21. 
Pruritus ani. 825. 
Pruritus vulvae, 203. 
etiology, 204. 
in kraurosis, 209. 
pathology, 203. 
treatment, 204. 
Pryor, 295, 304. 305. 555, 55S, 559. 
Pryor's operation for retro-displacements 

of uterus, 305. 
Psammoma of ovary. 621. 
Pseudo-hermaphroditism, 213. 
feminine, 126. 
masculine, 125. 
Pseudo-mucin, 606. 

test for, 606. 
Pseudo-mucinous cyst of ovary, contents. 
605. 
frequency, 603. 
histology, 606. 
section, illus., p. 605. 
symptoms, 604. 
Psychoses, as a result of oophoritis, 5S0. 
Pubertas precox, 124. 



Pubescent uterus, symptoms, 277. 

treatment, 277. 
Pubo-coccygeus muscle, 250. 
Pubo-rectalis muscle, 252. 
Pudendal hematocele, 135. 

infection of, 13S. 

symptoms, 137. 

treatment, 13S. 
Pudendum, definition, 117. 

hypertrophic and hyperplastic diseases 
of, 213. 

infections of, 163. 

neoplasms, benign, 221. 
malignant, 227. 
Puerperal fever, 52. 

infection, 10, 18. 17S. 

tuberculosis, 3S9 
Puncture, as means of diagnosis, 635. 
Pus, evacuation of, 54S. 

chancroidal, 183. 

gas-bearing, ISO. 

gonorrhceal. 515. 

post-operative, 6S. 
Pustules, papulo-, 199. 
Pysemia. 57. 

symptoms, 5S. 
Pyelitis. 76S. 

tuberculous, 773. 
Pyosalpinx, bacteria of, 4S5. 

contents of, 500. 

cultures from, 500. 

diagnosis, 50S, 510. 

etiology, 499. 

pain from, 506. 

pulse in, 506. 

relation to hydrosalpinx, 495. 

section from, 501. 

symptoms, 506. 

temperature. 506. 

Quadrants of abdomen, 41. 
Quain, 670. 
Quervain. 681. 
Quincke, 195. 

Rabenan. 3S3. 

Raciborsky, 710, 738. 

Radicalism in gynecology, 4. 

Ramsay, 7S6. 

Ranieri. 130. 

Rape, general indications, 159. 

hemorrhage from. 158. 

infection from, 15S. 

injuries from. 158. 

objective evidences, 156. 

pregnancy. 158. 
Ravogli. IS. 184. 187, 188, 189, 191, 192, 
193, 195, 196, 197, 19S, 199, 200, 202, 
204. 206, 215. 216. 
Raynaud. 712. 
Raynaud's disease, 196. 
Recamier. 1. 2. 36S. 447. 
Recklinghausen, von, 397, 401. 
Rectal infusion. 77. 
Rectocele, 238, 240, 257. 



892 



A TEXT-BOOK OF GYNECOLOGY 



Rectocele, anterior, 817. 

operations for, 269, 241. 

pathology, 818. 

posterior, 817. 

treatment, 818. 
Recto-vaginal fistula, illus., p. 151. 

etiology, 152. 

operation, 153. 

suture for, 153. 
Rectum, adenoma of, 841. 

adhesions of, 823. 

anatomy of, 806. 

angeioma of, 843. 

carcinoma of, 844. 

chancre of, 828. 

chancroid, 828. 

condylomata of, 828. 

curettage of, 846. 

dermoid cysts of, 844. 

displacements of, 817. 

divulsion of, 840, 846. 

enchondroma of, 844. 

etiology of diseases, 820. 

examination by, 39. 

examination of, 808. 

excision of, 847. 

fibroma of, 843. 

fistula of, 831, 835. 

foreign bodies in, 821. 

gonorrhoea of, 826. 

gummata, 829. 

infections of, 824. 

in pelvic inflammations, 822. 

lipoma of, 842. 

malformations, 806. 

malignant growths of, 844. 

myoma of, 844. 

neuralgia of, 820. 

papilloma of, 843. 

prolapse of, 120, 818. 

relation of diseases to intrapelvic dis- 
ease, 821. 

results of pressure on, 822. 

retention cysts of, 844. 

sarcoma of, 844. 

spraying of, 834. 

stricture of, 831, 837. 

syphilis of, 828. 

teratoma of, 844. 

tuberculosis of, 830. 

ulceration of, 820, 831, 833. 

valves of, 810. 
Reduction of inverted uterus, 328. 
Reed, 49, 57, 68, 70, 74, 98, 146, 209, 210, 
211, 231, 270, 282, 300, 310, 315, 316, 
325, 332, 339, 365, 400, 403, 410, 433, 
435, 443, 458, 542, 544, 552, 555, 578, 
582, 583, 588, 628, 805, 818. 
Reed's treatment of endometritis, 365. 

operation for vesico-uterine fistula, 344. 
vesico-vaginal fistula, 146. 

operation of panhysterectomy, 417. 

suture for incomplete laceration of 
perineum, 263. 
Regions of abdomen, 41; illus., p. 41. 



Rein, 703, 735. 

Reinecke, 716. 

Reis, Emil, 454, 458. 

Remy, 318. 

Repositor, uterine, 291, 328. 

Respiration in puerperal fever, 381. 

use of chloroform, 95. 
Rest, as a general remedy, 20. 
Restoration of pelvic floor, 258. 

levator-ani muscle, 71. 

posture for, 260. 
Retention of cervical fluid, 282. 

menstrual fluid, 282, 783. 
Retro-deviations of uterus, diagnosis, 289. 

symptoms, 289. 

treatment, 290. 
Reuss, 681. 
Reymond, 483, 492, 513, 515, 517, 518, 528, 

529, 530, 574, 580. 
Reynaud, 176. 
Rhabdomyomata, 783. 
Rhabdomyosarcomata, 783. 
Rhagades, 187. 
Rhazas, 328. 
Rheinstein, 525. 
Ricard, 392, 458. 
Richardson, 629. 
Richelot, 556, 559. 
Ricketts, Edwin, 678. 
Ricketts, B. M., 853. 

Ricketts's operation for hemorrhoids, 853. 
Rieck, 171, 173. 
Ring of Bandl, 332. 
Rishmiller, 636. 
Robb, 229, 575. 
Robin, 600. 

Robinson, 346, 711, 719. 
Robson, Mayo, 154, 155. 
Robson's operation for faecal fistula, 153. 
Rockel, 389. 
Rogivue, 437. 
Rohrer, 201. 
Rokitansky, 325, 385, 435, 480, 495, 525, 

575, 599. 
Rollin, 600. 
Room, operating, 64. 
Rosenbach, 57, 180. 
Rosenmiiller, 670. 
Rosenwasser, 372, 678. 
Ross, J. F. W., 45, 135, 142, 150, 403, 414, 

415. 
Rosthorn, 514, 601. 
Rothrock, 245, 246, 624. 
Round ligament, hydrocele of, 677. 

malformations of, 298. 

operations for shortening of, 294. 

Reed's forceps for, 300. 
Rousan, 683. 
Roush, 801. 
Rousset, 461, 464. 
Roux, Thomas, 368. 
Rovsing, 778, 791. 
Rubber gloves, 70, 295. 
Rubber, Turck's protective, 102. 
Rudimentary uterus, symptoms, 276. 



INDEX 



893 



Rudimentary uterus, treatment, 276. 
Rueff, 137. 
Ruggi, 294. 
Ruppolt, 474. 

Rupture of cysts of broad ligament, 675. 
ectopic pregnancy, 654, 661, 662, 663. 
hematocele, 137. 
ovarian cyst, 631. 
perineum, 255. 
pyosalpinx, 507. 
tubal papillomata, 480. 
uterus, 231. 
diagnosis, 332. 
etiology, 331. 
haemorrhage from, 335. 
mechanism, 331. 
pregnancy, 334. 
symptoms, 332. 
treatment, 333. 
vagina, 139. 
Rut, menstrual, 700. 

Sactosalpinx hemorrhagica, 499. 

purulenta, 499. 
Sahli, 25. 

Saline waters, 321. 
Salochin, 374. 
Salpingectomy, 549. 
drainage after, 553. 
enucleation of tumour mass, 555. 
history, 549. 
indications, 551. 
objections to, 550. 
Tait's operation, 551. 
technique, 552. 
toilet of peritoneum, 553. 
treatment of pedicle, 552. 
Salpingitis, acute, histology, 489. 

secretion in, 489. 
section (infiltration), illus., p. 491. 

section (replacement of mucosa), illus. 
492. 
catarrhal, 489. 
chronic, adhesions, 493. 

as cause of peritonitis, 493. 

bacteria of, 484. 

histology of, 491. 
Salpingitis, illus., p. 494. 
complications of diagnosis, 503. 
compression of bladder, 507. 
conservative operations for, 546. 
constipation in, 507. 
diagnosis, 501. 
distention of tube, 502. 
Doyen's operation, 556. 
drainage in, 540. 
dysmenorrhea in, 502. 
electricity in, 539. 
evacuation of pus, 548. 
extension of, 501. 
extravasation of blood in, 492. 
follicularis, 493. 
.gonorrheal, 507. 

diagnosis, 510. 

symptoms, 507. 



Salpingitis, hemorrhagic, 493. 
mechanical symptoms, 
menstruation in, 502. 
morbid histology, 489. 
pain from, 501, 502. 

palpation as a means of diagnosis, 503. 
panhysterectomy for, 555. 
peritoneal complications, 501. 
pseudo-follicularis, 492. 
purulent, 494. 
radical treatment, 549. 
secretion in, 493. 
separation of adhesions, 547. 
sterility from, 502. 
streptococcous, 507. 
symptoms, 507. 
diagnosis, 510. 
symptoms, 501. 
tuberculous, 511, 521. 
Salpingo-oophorectomy, 551. 
Salt solution, 74. 
infusion of, 76. 
Salve, resorcin, 194. 

Sanger, 70, 167, 245, 246, 247, 289, 294, 
427, 463, 470, 476, 478, 479, 638, 670, 
676, 677, 678, 679, 689. 
Sanger's closure in Csesarean section, 470. 
Saprsemia, 57. 

Saprophytic infection of Fallopian tubes, 
530. 
uterus, 377. 
pathology, 378. 
Sarcoma deciduo-chorio-cellulare, see Syn- 

cytioma malignum. 
Sarcoma of broad ligament, course, 686. 
treatment, 686. 
Fallopian tubes, 482. 
histology, 482. 
treatment, 482. 
kidney, 781. 
histology, 782. 
origin, 781. 
meatus urinarius, 200. 
ovaiy, frequency, 622. 
histology, 623. 
sections, illus., 624. 
symptoms, 623. 
urethra, 801. 
uterus, 432. 
etiology, 436. 
consistency, 432, 435. 
frequency, 432. 
hemorrhage in, 434. 
histology, 433. 
injection of, 436. 
inversion in, 433. 
origin, 435. 

papuliferous type, 433. 
recurrence of, 437. 
secondary degeneration, 434. 
treatment, 436. 
vagina, 232. 
adults, 232. 
children, 231. 
etiology, 232. 



894: 



A TEXT-BOOK OF GYNECOLOGY 



Sarcoma of vagina, histology, 233. 

vulva, 229. 
Sasonoff, 137. 
Satti, 697. 
Sauter, 447. 

Savages, menstruation in, 699. 
Savor, 769. 

Saw, spoon, 421; illus., p. 422. 
Sawizky, 55. 
Scanzoni, 674, 678, 739. 
Scar, abdominal, 105. 
Schaeffer, 131. 
Schatz, 69, 272, 674. 
Schauta, 348, 349, 391, 513, 528, 530, 579, 

580, 665. 
Schedule for determination of rape, 160. 
Schenck, 171, 681. 
Schetelig, 678. 
Scheurlen, 441. 
Schick, 367. 
Schiller, 373. 
Schleich, 97. 

Schleich's anaesthetic mixture, 97. 
Schlenker, 615. 
Schlesinger, 549. 
Schmidt, 678, 769. 
Schmorl, 389, 562. 
Schniir, 763. 
Schonheimer, 733. 
Schottlander, 575, 576. 
Schramm, 521. 
Schroeder, 171, 175, 366, 435, 440, 525, 638, 

671, 678, 692, 730. 
Schuckhardt, 520. 
Schiicking, 76. 
Schiill, 389. 

Schultze, 362, 363, 372. 
Schiitt, 385. 
Schwartz, 227, 392. 
Searcher, ureteral, 747. 
Section, abdominal, 99. 

Caesarean, 460. 
Secretion of cervix, 353. 
retention of, 282. 
operation for retention, 279. 

endometrium, 350. 

vagina, 164, 351. 

vulvo-vaginal gland, 243. 
Segond, 529, 554, 682. 
Segregator, urine, 747. 
Seleneff, 374. 
Semen, stains from, 158. 
Semnopithecus, menstruation of, 699. 

ovulation of, 710. 
Senator, 780. 

Senn, 67, 68, 678, 679, 681, 843. 
Sepsis, bacteria of, 50. 

definition of, 50. 

general, 57. 
symptoms, 58. 
treatment, 58. 

local, 56. 
symptoms, 56, 73. 

preventive treatment, 66. 
Septate uterus, 277. 



Septate uterus, menstruation from, 277. 

pregnancy in, 277. 

symptoms, 277. 
Septicaemia, see Sepsis. 
Serous cysts, 607. 

contents, 608. 

frequency, 607. 

histology, 608. 
Serpentine suture, 111. 
Serum therapy, 21, 44, 45. 

in general sepsis, 59. 
Sex, differentiation of, 117. 
Sexual anaesthesia, 9. 

perversions, 9. 
Seydel, 549. 
Shock, causes, 72. 

definition, 72. 

diagnosis, 73. 

pathology, 72. 

symptoms, 72. 

treatment, 74, 630. . 
Silk ligature, 86. 

Simon, G., 144, 230, 447, 541, 635. 
Simon-Hegar operation for complete lac- 
eration, 270. 
Simon's speculum, 371. 
Simpson, 2. 

Simpson, Sir James, 91, 312, 950. 
Sims, J. Marion, 2, 42, 143, 145, 146, 154,. 
305, 312, 313, 314, 323, 326, 337, 368, 
420, 425, 445, 448, 452, 538, 726, 730. 
Sims's operation for urinary fistula, 144. 

posture, 33. 

speculum, 142. 
Sinclair, 352, 355, 356, 357, 361, 364, 484, 

487, 530. 
Sinus, urogenital, 122. 
Sippel, 385, 391, 453, 588, 692, 697. 
Sitz bath, 204. 

Skene, 84, 85, 148, 244, 419, 448, 642, 681. 
Skene's gland, 244. 

gonorrhoea of, 244. 
Skin, disinfection of, 295. 

of genitalia, 191. 
Skirving, 121. 
Slansky, 478. 
Smith, Albert, 293. 
Smith, Greig, 681. 
Smith, Nathan, 638. 
Smith, Tyler, 329. 
Sneguireff, 364. 
Social evil, as cause of diseases of women,. 

10. 
Solowieff, 353. 
Solution, Burow's, 196. 

Florence, 158, 159. 
Soranus, 1. 
Sound, 32. 

as means of diagnosis, 45. 

dangers of, 291. 

Ross's intrauterine, 45. 

uterine, 345. 
Spaeth, 324, 385, F87. 
Specialism in gynecology, 2. 
Speculum, as means of examination, 42- 



INDEX 



895 



Speculum, Gau's, 44; illus., p. 43. 

infection from. 362. 

Jones's, 370. 

Miller's, 44. 

Xott's, 44. 

Simon's, 371. 

Sims's, 32; illus., p. 42. 

Sims-Emmet, 43. 

vesical. 740. 
Spermatozoa, determination of, 159. 
Speth, 4S1. 
Sphincter-ani-externus muscle, 250. 

restoration of, 269. 
Sphincter vagina muscle, 237. 
Spiegelberg. 137, 671, 074. 
Sponge holder. 450. 
Spores, annihilation of. 61. 
Spronius, 549. 
Staffordshire knot. 552. 
Stains, seminal, 158. 
Standing posture, 35. 
Stanley. 24. 
Staphylococcus epidermidis albus. 51. 

infection, 196, 530. 

pyogenes albus, 51, 196. 
aureus, 50, 53. 
citreus. 52. 
St. Braunwas. 334. 
Steffeek, 610. 
Steinitz, 797. 
Steinmetz. 799. 
Steinschneider, 514. 
Stemann. 524. 
Stenosis, as cause of dysmenorrhoea, 726. 

electricity in. 730. 

operation for, 2S1. 

uterine, 2S0. 

vaginal, 129. 
Stephenson. 707. 
Stephenson's wave, 707. 
Sterility, 502, 509. 

etiology. 141. 
Sterilization, germicidal agents for, 63. 

heat for, 61. 

mechanical means, 61. 
Sterilization of, dressings, 66. 

hands, 69. 

instruments, 66. 

operating room, 64. 

patients, 66. 

surgeon. 69. 

sutures and ligatures, 67. 

vagina. 313. 
Sterilizer, steam, of Colonel John Fehren- 

batch. 61: illus., p. 61. 
Sternberg. 51. 53. 61. 

Stethoscope, as means of examination. 47. 
Stevenson. 24. 
Stille, 376. 
Stirton. James, 699. 
Stockard. 397. 
Stoecklin. 571. 
Stoltz. 463. 

Stomach, menstruation from, 736. 
Stomatoplasty, illus., p. 2S0. 



' Stomatoplasty, indications for, 282. 
technique, 283. 
Storer, 471. 
Stratz. 401. 

Streptococcous infection of external geni- 
talia, 177. 
treatment, 178. 
Fallopian tubes, 516. 
diagnosis, 516. 
fimbria, 517. 
mucosa in, 517. 
palpation of, 516. 
pathology, 517. 
pus from. 517. 
symptoms, 516. 
ovaries, 569. 
course, 569. 
pathology, 571. 
treatment, 5S1. 
uterus, 376. 
diagnosis, 381. 
pathology, 376. 
symptoms. 380. 
treatment, 3S1. 
pudendum. 177. 
vagina, 177. 
Streptococcus pyogenes, 52: illus., p. 52. 

erysipelatos, 52. 
Streptothrix actinomyces, infection of 

Fallopian tubes, 531. 
Stricture, of rectum, carcinoma as a 
cause, 838. 
etiology, 837. 
diagnosis, 839. 
dysenteric, 838. 
symptoms, 838. 
syphilitic. 838. 
traumatic, 838. 
treatment, 839. 
tuberculous, 838. 
ureter, 760. 
dilatation of. 761. 
operation for, 761. 
urethra. 802. 
etiology. 802. 
treatment, 802. 
Stroganoff, 163, 165, 353, 530. 
Struma suprarenalis lipomatodes aber- 

rans, 785. 
Styptics. 79. 
Subcostal incision. 106. 
Subcutaneous infusion. 76. 
Suggestion as a therapeutic agency, 23. 
Superinfection, gonococcous, 375. 
Suppinger, 120. 
Suppuration, 55. 

pelvic, 
Suprapubic incision, 106. 
Suprarenal extract, 75. 
Supravaginal hysterectomy, 410. 
indications. 411. 
instruments. 103. 
technique. 412. 
Surgeon, preparation for examination, 33. 
sterilization of, 69. 



896 



A TEXT-BOOK OF GYNECOLOGY 



Sutton, Bland, 475, 478, 480, 489, 493, 495, 

497, 552, 558, 588, 589, 617. 
Suture, buried serpentine, 111. 
catgut, 67. 
crown, 
Emmet's, 262. 
Reed's, 263. 
en masse, 112. 
figure-of-eight, 113. 
intercutaneous, 110. 
laminated, 109. 
removal of, 340. 

after urinary fistula, 150. 
sterilization of, 67. 
wire, 144. 
Syms, Parker, 698. 
Syncope, 73. 

Syncytioma malignum, 15, 231, 426. 
diagnosis, 428. 
etiology, 428. 
hemorrhage in, 428. 
histology, 427. 
metastasis in, 429. 
pain in, 428. 
pathology of, 427. 
results of operation, 429. 
source of, 427. 
symptoms, 428. 
treatment, 429. 
Syncytium, action of, 655. 

in ectopic pregnancy, 660. 
Syphilis, as cause of pelvic diseases, 11. 
bacteriology of, 186. 
from rape, 158. 
Syphilis of broad ligament, 690. 
histology, 690. 
diagnosis, 690. 
external genitalia, 17, 189. 
uterus, 391. 
cauterization in, 393. 
diagnosis, 393. 
primary, 392. 
secondary, 392. 
symptoms, 392. 
treatment, 393. 
rectum, congenital, 828. 
stricture from, 838. 
treatment, 829. 
Syringe, Davidson's, 76. 
Szancer, 394. 

Table, Bozeman's, 143. 
Tachycardia at menopause, 740. 
Tait, Lawson, 2, 99, 126, 137, 144, 154, 
166, 210, 216, 266, 267, 269, 271, 272, 
306, 328, 329, 345, 347, 350, 352, 353, 
357, 584, 586, 637, 638, 640, 641, 649, 
689, 709, 805. 
Tait's operation for complete laceration 
of perineum, 267. 
removal of Fallopian tubes, 551. 
Tampon, chain, 292; illus., p. 292. 
improper, 292; illus., p. 292. 
lamb's wool, 293; illus., p. 293. 
method of inserting, 537. 



Tampon, proper, 292. 
Tampon for, bleeding, 215. 

carcinoma uteri, 445. 

diagnosis of endometritis, 363. 

eczema, 197. 

gonorrhoea of uterus, 375. 

inversion of uterus, 329. 

menorrhagia, 716. 

prolapsus uteri, 322. 

pruritus vulvae, 204. 

puerperal fever, 382. 

salpingitis, 537. 

uterine displacement, 291. 
Tarulli, 589. 

Taylor, George H., 24, 182. 
Temesvary, 624. 

Temperature, in puerperal fever, 380. 
Tenacula, 371. 

Cullen's, 450. 
Tent, laminaria, 356. 
Teratoma, of ovary, 614. 

of rectum, 844. 
Testicle, coexistence of, with ovary, 562. 
Thayer, 514. 
Themison, 328. 

Therapeutics of gynecology, 20. 
Therapy, serum, 21. 
Thiem, C, 161. 
Thiriar, 310, 315. 

Thomas, Gaillard, 293, 322, 329, 429, 447. 
Thomas's serrated spoon saw, 421. 
Thomson, 279, 318, 754. 
Thorn, 389, 458. 
Thornton, 628, 638. 
Thrush, 179. 
Thumin, 81. 
Thyroid gland, extract of, 21. 

as a styptic, 79. 

relation to uterus, 21. 
Tillaud, 388. 
Tilt, 738. 

Tongue forceps, 95. 
Toxaemia, 57. 

Toxine, treatment with, 436. 
Trachelorrhaphy, illus., p. 339. 

instruments for, 338. 

sutures for, 339. 

technique, 338. 
Transfusion of blood, 76. 
Transversus-perinaei muscle, 250. 
Trekaki, 754. 
Trendelenburg, 304, 315. 

posture, illus., p. 454. 
Treub, 325, 327. 
Trichophyton tonsurans, 205. 
Trifid uterus, 275. 
Trocar, illus., p. 640. 
Trommer, 606. 
Trophoblast, 657. 
Tsokana, 149. 
Tubercle, genital, 117. 

double, 121. 
Tuberculosis, bacillus of, 55. 
Tuberculosis, of bladder, 792. 

broad ligament, 691. 



INDEX 



897 



Tuberculosis, of cervix, 385. 

classification, 385. 

diagnosis. 386. 

diffuse form, 386. 

etiology, 385. 

miliary form, 385. 

morbid anatomy. 385. 

papillary form, 386. 

resemblance to epithelioma, 387. 

symptoms, 386. 

treatment, 387. 
Fallopian tubes, 519. 

acute, 524. 

adenomatous tumour formations 525. 

ascending form, 520. 

chronic, 324. 

complications of. 526. 

descending form, 521. 

diagnosis, 526. 

distention from, 522. 

frequency of, 520. 

gonococcus in, 525. 

hematogenous infection, 521. 

menstruation in, 526. 

method of infection, 520. 521. 

morbid anatomy of, 521. 

mucosa in, 524. 

pain in, 526. 

primary, 520. 

prognosis of, 527. 

secondary, 520. 

spontaneous cure, 525. 

symptoms, 525. 

treatment, 527. 
kidney, 772. 

abscesses in, 773. 

changes in urine, 774. 

diagnosis, 774. 

frequency of, 772. 

giant cell, illus., p. 773. 

hematuria in, 774. 

involvement of ureter. 774. 

method of infection, 772. 

pain in, 774. 

pathology, 773. 

symptoms, 774. 

treatment, 775. 
ovary, 575. 

diagnosis, 577. 

frequency of, 575. 

mode of infection, 576. 

morbid anatomy, 576. 

symptoms, 577. 

treatment, 578. 
peritoneum, 692. 

anatomy, morbid, 692. 

caseous variety, 693. 

diagnosis of, 695. 

drainage in. 697. 

etiology, 692. 

fever in, 694. 

fibroid variety, 694. 

miliary variety, 692. 

omental tumour in, 695. 

pain from, 694. 
58 



Tuberculosis, of peritoneum, prognosis, 

results of operation, 697. 

symptoms, 694. 

treatment, 696. 
rectum, 830. 

etiology, 830. 

fistula from, 830. 

forms of, 831. 

stricture from, 831, 838. 

symptoms, 831. 

treatment, 832. 
urethra, 173. 
uterus, 357, 384. 

caseous form, 390. 

cauterization of, 391. 

course of infection, 388. 

curettage for, 391. 

diagnosis of, 390. 

discharge in, 390. 

etiology, 388. 

fibroid type, 390. 

glands in, 391. 

hysterectomy for, 391. 

miliary form, 389. 

morbid anatomy, 389. 

pathology, 389. 

pregnancy in, 389. 

symptoms, 390. 

treatment, 391. 
vagina, 175. 

diagnosis, 177. 

etiology, 175. 

symptoms, 176. 

treatment. 177. 
vulva, 17. 165. 

diagnosis of, 174. 

etiology of. 171. 

morbid anatomy, 172. 

symptoms, 174. 

treatment, 175. 

Tubes, accessory, 749. 

drainage. 112. 114. 

through -and-through, 542. 
Fallopian, see Fallopian tubes. 
Kobelt's, 671. 
supernumerary, 474. 
Tubo-ovarian cyst. 69, 601. 
classification, 601. 
contents, 602. 
etiology, 601. 
histology, 602. 
origin, 418. 
Tuckerman, 778. 
Tuffier, 81, 97, 528, 772. 
Tumours, see Neoplasms. 
Turck, 75, 102. 

Turck's intragastric resuscitator, 75. 
protective rubber, 102. 

Ulcer, anal, 832. 

destructive. 171. 

follicular, 181. 

syphilitic, 189. 
Ulceration, of rectum, 820, 831. 

diagnosis of, 834. 



898 



A TEXT-BOOK OF GYNECOLOGY 



Ulceration, of rectum, symptoms, 833. 

treatment, 834. 
Ulcus elevatum, 186. 

rodens vulvae, 171. 
Umbilical incision, 106. 
Unicornate uterus, 276. 
Urachus, anatomy of, 803. 

cyst of, 804. 
Ureters, anomalies of, 760. 

catheterization of, 744. 

duplication of, 760. 

injuries of, 762. 

in hysterectomy, 413. 

in nephrectomy, 789. 

involvement of, in carcinoma, 786. 

operations on, 761. 

stricture of, 760. 
Uretero-cystotomy, 761. 
Uretero-vaginal fistula, 140. 

operations for, 151. 
Urethra, atresia of, 150. 

carcinoma of, 801. 

caruncle of, 800. 

dilatation of, 803. 

diseases of, 800. 

diverticula of, 801. 

foreign bodies in, 802. 

prolapse of, 802. 

sarcoma of, 801. 

stricture of, 802. 

tuberculosis of, 173. 
Urinary apparatus, examination of, 744. 

fistulae, 139. 
Urines, bacteria of, 779. 

examination of, 102. 

incontinence of, 123, 134, 141. 

in cystitis, 793. 

in renal infection, 771. 

residual, 239. 

segregation of, 747. 

suppression of, 779. 
Urogenital sinus, 123. 

persistent, 122. 
Uronephrosis, see Nephrydrosis. 
Urticaria of Wilson, 195. 
Uterus, absence of, 276. 

accessorius, 275. 

adenoma of, 429. 

adenomyoma of, 397, 399. 

ante-deviations of, 310. 

atrophy of, 18. 

bacteria of, 352. 

bicornate, 281. 

carcinoma of, 437. 

chancre, 391. 

contraction of, 468. 

curettage of, 368. 

development of, 274. 

displacements of, 38, 284. 

double, 281. 

echinococcous, cyst of, 394. 
infection of, 393. 

endothelioma of, 434. 

examination of, 47. 

fibromyomata of, 396. 



Uterus, fcetal, 277. 
foreign bodies in, 348. 
gonorrhoea of, 354, 372. 
in menorrhagia, 715. 
infantile, 277. 
infection of, 16, 350, 372. 
injuries of, 162, 331. 
inversion of, 324. 
lymphatics of, 350. 
malformations of, 274, 279. 
malignant neoplasms of, 426. 
menstrual function of, 13, 708. 
movements of, 284. 
myoma of, 396. 
neoplasms of, 396. 
normal position of, 284. 
poise of, 15. 

polypoid growths of, 424. 
prolapse of, 161, 275. 
pubescent, 277. 
repositor for, 291, 328. 
rudimentary, 276. 
rupture of, 331. 
saphrophytic infection of, 377. 
sarcoma of, 432. 
septus, 277. 
stenosis of, 280. 

streptococcous infection of, 376. 
suspensory apparatus of, 285. 
suture for, in Csesarean section, 468. 
syncytioma malignum of, 231, 428. 
syphilis of, 391. 
trifid, 275. 

tuberculosis of, 357, 384. 
unicornate, 276. 
vaginal fixation of, 303. 
wounds of, 345. 

Vagina, absence of, 126. 
atresia of, 163. 
Bilharzia of, 180. 
carcinoma of, 233. 
coitional, 128. 
cysts of, 224. 
dermoid cyst of, 225. 
displacements of, 237. 
douche for, 32. 
endothelioma of, 233. 
examination by, 30, 165. 
extirpation of, 455. 
fibroid tumours of, 225. 
infections of, 16, 163. 
injuries of, 139, 162. 
malformations of, 126. 
neoplasms of, 224. 

malignant, 231. 
Mullerian, 126. 
polyps of, 226. 
prolapse of, 237. 
sarcoma of, 231. 
secretions of, 164, 351. 
septate, 129. 
stenosis of, 129. 
sterilization of, 313. 
tuberculosis of, 175, 



IXDEX 



899 



Vagina, virgin, 252. 
Vaginal hysterectomy, 419. 

instruments, 103. 

myomotomy. 420. 
Vaginitis, 163. 

exfoliative, 167. 
Valve, rectal, 810. 
Valvotome, 836. 
Van Buren, 841. 
Vander Veer, 403, 647. 
Van de Warker, 9. 
Van Gieson, 480. 
Van Heukelom, 427, 657. 
Van Hook, 761. 762. 
Van Schaick, 372, 373. 
Varicocele, pelvic, 682. 

diagnosis, 684. 

etiology. 683. 

history, 684. 

Reed's operation for, 685. 

symptoms, 684. 
Varicocele, pudendal, 222. 
Varix, aneurismal, of broad ligament, 682. 
Vassmer, 385, 388, 389, 390. 
Veins of labia, 221. 
Veit. 171. 224. 226. 232. 318. 391, 397, 429, 

434, 470, 499, 521. 522. 525. 
Velits, von, 626. 
Ventral fixation, 306. 

incision, 106. 
Verneuil. 711, 849. 
Vertical median incision. 105. 
Vesicles, herpes progenitalis, 201. 
Vesico-umbilical fistula, 804. 
Vesico-uterine fistula, 140, 343. 

diagnosis. 343. 

Reed's operation, 344. 
Vesico-vaginal fistula, 139. 
Vestibular band. 134. 
Vibrion septique, 531. 
Vidal. 377, 379. 

Vineberg. 129. 276. 294. 304, 383. 
Vinegar a-? a styptic. 79. 
Violence, injuries from, 136. 
Virchow, 432. 435. 575, 609, 678. 
Virgin, examination of. 30. 

vagina, 252. 
Virus, chancroidal, 183. 
Vitrac, 387. 
Volbrecht, 677. 
Volsella. Newman's. 338. 
Vomiting in anaesthesia, 91. 
Von Eiselberg. 51, 57. 
Von Guerard, 367. 
Von Kohlden, 351, 352, 370. 
Von Langenbeck. 447. 
Von Rosthorn. 496, 574. 
Vulva. 117. 

adhesions of. 211. 

atresia of. 119. 

atrophy of, 207. 

blood supply of. 221. 

carcinoma of, 227. 

chancre of, 228. 

cloaca, 121. 



Vulva, cysts of, 223. 

eczema ot, 196. 

elephantiasis of, 216. 

enchondromata of, 223. 

fibromata of, 222. 

fibroma molluscum of, 223. 

fibrosarcoma of, 229. 

folliculitis of, 198. 

hematoma of, 222. 

hemorrhage from, 135. 

hypertrophy of, 213. 

infantile. 120. 

injuries of, 135, 157, 162. 

intertrigo of. 191. 

lipomata of, 223. 

malformations of, 118. 

malignant neoplasms of. 227. 

melano-carcinoma of, 231. 

melanosarcoma of, 229. 

metastases in, 231. 

molluscum pendulum of, 223. 

myomata of, 222. 

myxofibromata of. 223. 

myxosarcoma of. 229. 

neuromata of, 223. 

noma of, 169. 

oedema of. 195. 

polypi of. 219. 

precocious development of, 124. 

pruritus of, 202. 

pseudo-hermaphroditism, 126. 

sarcoma of, 229. 

tuberculosis of, 171. 

varicose tumours of. 221. 
Vulvitis. 163. 
Vulvo-vaginal anus, 122. 
Vulvo-vaginal gland, abscess of, 245. 

anatomy, 243. 

carcinoma of. 228, 249. 

cysts of, 224, 247. 

function of. 243. 

gonorrhoea of, 170. 

infection of. 243. 

inflammation of. 144. 

Wagner, 7S7. 

Waldeyer. 602. 670. 689. 

Waklstein. 233. 

Wallace. J. R., 737. 

Walt her, 389, 391. 

Walton, P.. 128, 129. 

Warburg. 536. 

Warnecke. 697. 

Warren. 70. 73. 74. 

Wart, venereal, see Condylomata. 

Wave, Stephenson's, 707. 

Weber, 248, 681. 

Webster, 126, 203, 205. 

Weigert. 694. 

Weight of brain. 7. 

Weir. R. F.. 70. 207. 

Welch. 52, 54, 180, 358. 

Wells, Spencer, 2, 627, 636, 638, 640, 642, 

676. 
Werder, 455. 



900 



A TEXT-BOOK OF GYNECOLOGY 



Wernitz, 229. 

Werth, 56, 610, 670. 

Wertheim, 199, 294, 354, 356, 374, 375, 485, 

486, 513, 515, 529. 
Westermark, 485, 513. 
Westermeyer, 576. 
Westphalen, 13. 
Wetherill, 474. 
Whitacre, 228, 384, 385, 387, 491, 493, 576, 

577. . 
White, J. W., 216, 329, 781. 
Whitehead, 392, 821. 
Whitehead's operation for hemorrhoids, 

852. 
Wiart, Pierre, 477. 
Wicklein, 180. 
Widal, 52, 376. 
Wilhelrn, 671. 

Wilson's ointment, 193, 200. 
Williams, 386, 389, 473, 474, 475, 480, 

520, 521, 524, 525, 562, 610, 617, 692, 

627. 
Williams, J. Whitridge, 164, 165, 293. 

427, 615. 
Williams, Roger, 427, 429, 433, 436. 
Wilms, 14, 613. 
Wincke, F. von, 274. 



Winckel, 137, 229, 289, 474, 525, 561, 676, 

678, 679, 681, 682. 
Wing, 329. 

Winter, 164, 353, 360, 437, 484, 598. 
Withrow, 653, 720, 736. 
Witte, 484, 513, 528, 530, 531, 574, 575. 
Witzel, 801. 
Wladimiroff, 702. 
Wolf, 249, 805. 
Wolff, 525, 575, 577. 
Wolffian body, 117. 

ducts, 126, 671. 
Wounds of uterus, 345. 
Wumschein, 769. 
Wyder, 351. 
Wylie, 294, 299, 679. 
Wyssakovitseh, 60. 

Zahn, 389. 

Zeman, 531, 575. 

Zetter, 627. 

Ziegler, 597, 621. 

Zinke, 675, 678, 679, 680, 682, 683, 684, 685, 

686, 687. 
Zuckerkandl, 689. 
Zweifel, 180, 387, 470, 495, 513, 529, 530, 

556, 574. 



THE END 



A TEXT-BOOK OX SURGERY: 

GENERAL, OPERATIVE, AXD MECHANICAL. 

By JOHX A. WYETH, M. D., 

Professor of Surgery in the New York Polyclinic ; Surgeon to Mount Sinai Hospital, etc, 

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The original edition of this work was published in 1886. It was revised and 
enlarged in a second edition in 1890. AVithin the period of seven years to this 
date (November, 1897) so many important advances have been made in surgical sci- 
ence and the operative technique that the author has found it necessary again to 
revise and practically rewrite this volume. To add all that was new and acceptable 
to that which experience had already demonstrated to be useful has of necessity 
increased the number of pages and size of the book. By careful elimination of 
matter which could with least disadvantage be left out, this volume, however, only 
exceeds the former by one hundred and twelve pages. 

It has been the author's aim to retain those features of the original work which 
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undergraduate pupils. With this end in view the matter has in great part been 
rearranged. 

The introductory section is devoted to surgical pathology, subdivided into six 
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Chapters XIII, XIV. and XV deal with the lymphatic vessels and glands, veins, 
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The chapters from XVIII to XXIX inclusive are devoted to regional surgery, 
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Surgery, as presented in the present volumes, is a translation of his works on General 
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THE DISEASES OF 
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" When one recalls the teachings of a decade or two ago and compares the inculcations 
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THE DISEASES OF THE 
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By Dr. C. A. EWALD, 

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valuable data added, the work is a sine qua ?wn." — Atlanta Medical and Surgical 
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" This work as it now stands is the best on the subject of stomach diseases in 
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" The present American edition is a peculiarly valuable one, as the editor. 
Dr. Manges, has done his work in a thoroughly creditable manner. His numer- 
ous notes, additions, and new illustrations have made the book a classic one. 
Under these circumstances it should find a place in the library of every Amer- 
ican physician, as their clientele is composed of such a large proportion of patients 
suffering from gastric complaints and more or less improper medication which 
most often ends in failure. There is no doubt that more properly directed efforts 
in the proper direction, as outlined in Ewald's book, would soon remove from 
Americans the reputation of being a nation of dyspeptics." — St. Louis Medical 
and Surgical Journal. 

" Dr. Ewald's book has met with a very cordial reception by the medical pro- 
fession. Within a short period three editions have appeared, and translations 
published in England, Spain, France, Italy, and the United States. To the 
present edition the author has not only added considerable new matter, but he 
has also entirely rewritten the work. The arrangement of the chapters has been 
somewhat changed, and many new personal observations and therapeutic experi- 
ences added. The desirability of surgical interference is carefully considered, and 
the pros and cons given so far as would be necessary to enable a physician to 
determine whether the aid of the surgeon might be required. The translator has 
done his work well, and has incorporated much new matter into the text and 
footnotes." — North American Journal of Homoeopathy. 



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